Slide 1
INTEGRATED CARE AMADORA &
VALENCIA PILOT SITES EXPERIENCE
Lucas Donat
Project Manager- eRPSS Joint
Unit Research
Adriano Fernandes
Project Manager

Slide 2

Slide 3
0. Amadora_An overview

Slide 4
MISERICÓRDIA DA AMADORA

Slide 5
2. SOCIAL&HEALTH CARE SERVICES

Slide 6
4. INTEGRATED CARE_a reality now in Amadora

Slide 7
Usual Care Integrated Care
Social Care
(Hygiene&Alimentation)
Social&Health Care
Tele-Assistance Tele-Assistance&Tele-Monitoring
Lack of structured Training to
Formal/Informal Carers
Structured Training to
Formal/Informal Carers
Lack of ICT Components/Tools
Online Platform (PAD) with Tele-
Monitoring&Tele-Assistance
integration; b-Learning tool
More people institucionalized due
to lack of Services/Conditions at
home
Enhancing the possibility to
continue living@home
BEYOND SILOS_List improvements usual care VS
integrated care

Slide 8
BEYOND SILOS_Scope

Slide 9
BEYOND SILOS_Technological
Adaptation

Slide 10
5. INTEGRATED CARE TRIGGERS CHANGE
MANAGEMENT/LESSONS LEARNED

Slide 11
6. BEYOND SILOS_SWOT

HEALTH CARE
DEPARTMENT
VALENCIA LA FEVALENCIA LA FE

Slide 13
HEALTH CARE DEPARTMENT VALENCIA LA FE http://www.hospital-lafe.com
» Health Care Department Valencia La Fe involves
Hospital La Fe, six basic Health Primary Care Areas &
auxiliary centers and a Health Research Institute.
» Hospital Universitari i Politècnic La Fe is a public
hospital with direct management with more than 40
years of history (since 1969), with more than 7.000
professionals
• Pioneer in chronic care management model,
project with high complex chronic patients results
shows an increase of life quality and a decrease of
unplanned hospital admissions as well as a descent of
77% in the unplanned stays
• More than 300 researchers, 500 scientific works
published and 7.830 quotes in 2011
EVERY YEAR
» More than 50.000
admissions in hospital
» More than 385.000
hospital stays
» 6.000 childbirths
» More than 36.000
surgery operations, 50%
without admission
» More than 500.000
outpatient medical visits
» More than 250.000
emergency assistances
» More than 25.000 home
hospital-based visits
3 STARS Reference
Site on EIP-AHA

Slide 14
Healthcare department Valencia La Fe wants to be:
» One of the best integrated healthcare services system in Europe
» Recognized as an excellent organization
» One of the best healthcare systems in Europe, which means keep an active
effort to place itself in:
- The top five Spanish hospitals in efficiency and satisfaction
- The top five Spanish hospitals and the top fifty European hospitals: quality,
activity, patient attraction and sustainability.
Mission
Vision
“Innovation and experience at the patient’s service”
Values » The citizen is the organization’s point of reference and action. The main
resource is people, who practice their mission in accordance with the
following values:
Enterprising attitude and overcoming effort
Flexibility and adaptability for innovation
Self-respect, teamwork and idea of group membership
Professional ethic sense
Environmental respect

Footer text (change in slide master) Slide 15
Case Management Care Program

Footer text (change in slide master) Slide 16
Adaptation of an existing integrated care service for complex
multimorbid patients across care levels.
Beyond Silos Challenges

Slide 17
Valencia deployment site: Technological platform
ATENZIA Building Blocks
SchedulingScheduling
AlertsAlerts
Data
management
Data
management
Personal
Data
Protection
Personal
Data
Protection

Slide 18
Valencia Deployment Site: Technological Platform

Slide 19
Usual Care Integrated Care
Patient call every three
weeks during working hours (8-
15h)
Patient Call every 15 days and 24/7
covered
Patient social evaluation during
hospital stay and during inclusion
in CMP
Patient social evaluation during
inclusion, and every 4 months in
new care model . Closer follow-up
Physiological measurement when
patients receives/goes GP visits
Physiological measurement sent by
patient every week through PC
tablet
Educational intervention during
inclusion in CMP
Educational Intervention at the
inclusion and during follow-up
(trough PC tablet or presentially)
Transitions care from STC to LTC
focused in clinical care
Transitions care has both
perspectives Clinical and social
BEYOND SILOS_List improvements usual care VS
integrated care

Adapting care processes. "Case Management"
PRIMARY HEALTH
CARE TEAM
Telemedicine CASE
MANAGEMENT (CM)
HOSPITAL
AT HOME
UNIT
MEDICAL
AREA
OUTPATIENT SERVICES
PATIENT
CAREGIVER
Community nurse CM
Hospital nurse CM
AMBULATORY
CARE
COMPLEX
AMBULATORY
CARE-HaH
EMERGENCY
SHORT-TERM UNIT
SURGICAL/MEDICAL
UNITS
MEDIUM/LONG
TERM UNIT
EDUCATION AND
SECUNDARY
PREVENTION
PROGRAM
HEALTH CENTER
CARE
HOME CARE
Barthel I. <30
Follow-up, as usual
ATENZIAATENZIA
TechnologyTechnology

Slide 21
BEYOND SILOS_SWOT

Slide 22
MOLTES GRÀCIES!
MUITO OBRIGADO!
THANK YOU SO MUCH!
Lucas Donat : lucas_donat@iislafe.es
Adriano Fernandes: adrianofernandes@misericordia-amadora.pt