Chronic Disease Management: tools for balancing an increasing expenditure and a limited budget…with well-cared patients - José Augusto García Navarro

WB Seminar
Washington DC, 11th September 2017
Chronic Disease Management: tools for balancing an
increasing expenditure and a limited budget…with well-
cared patients
José Augusto García Navarro
http://www.consorci.org

ImprovingPublic
HealthcareQuality
inCatalonia
Knowledge Generation in healthcare delivery
Human resources
Hospitals management and Consultancy

TheCSC
(CatalanHealthand
SocialCareConsortium)
1. Health and Social Care Centers
2. Facilities:
1. 42 General Hospitals
2. 57 Primary care centers
3. 171 nursing homes
4. 54 Postacute and intermediate care hospitals
5. 15 Mental Healthcare Centers
6. 25 Others (Laboratory, X-ray diagnosis, etc.)
3. 80% Hospital Discharges in Catalonia
4. 74% primary healthcare Centers
5. 45.000 Employees

Population over 65s doubles in 2039
Population over 85s quadruples in 2039
Average pension is reduced by a third
Population is aging and facing poverty

Unstoppable Expansion of New Treatments
 Biologic therapies start to be prescribed by Primary Care Physicians
The Economist, Jan 3rd 2015. Going Large.

Where to Begin?Where to Begin?Where to Begin?Where to Begin?
Primary care and Community ProgramsPrimary care and Community ProgramsPrimary care and Community ProgramsPrimary care and Community Programs
TheThe ““DeconstructionDeconstruction”” of Hospitalsof HospitalsTheThe ““DeconstructionDeconstruction”” of Hospitalsof Hospitals
ConclusionsConclusionsConclusionsConclusions

Population Health Plan 2016-2020Population Health Plan 2016-2020Population Health Plan 2016-2020Population Health Plan 2016-2020
Plans to manage chronic diseases in Catalonia
http://salutweb.gencat.cat/ca/el_departament/Pla_salut/pla-de-salut-2016-2020/

Evolution of life expectancy for people born in Catalonia 1983-2013
Population Health Plan 2016-2020

Main chronic disorders among the 15+ age group in Catalonia,
2014

Population health and lifestyle habits, by gender, 2011 to 2014

Prevalence of tobacco consumption among the 16-64 people, by
employment status and gender, 2006 and 2013-2014

BMI by gender, 18 to 74 age group. Catalonia 2014

Population Health Plan 2016-2020: Setting Targets

Population Health Plan 2016-2020: Evaluation

Programme for Prevention and TreatmentProgramme for Prevention and Treatment
of Chronicity in Catalonia (PPAC)of Chronicity in Catalonia (PPAC)
Programme for Prevention and TreatmentProgramme for Prevention and Treatment
of Chronicity in Catalonia (PPAC)of Chronicity in Catalonia (PPAC)

Level 2
People with Chronic Diseases at
Risk
Case
Management
Disease
Management
Self-Management
Support
Level 1
People with Stable Chronic
Diseases
Level 3
Complex
Patients
Comorbidity, Hospitalizations and
Frequent Emergency Visits,
Moderate and Severe Functional
Dependence,…
Health Promotion Healthy People
Stratification + Clinical View(!)

Interdepartamental Plan for Health andInterdepartamental Plan for Health and
Social Care (PIAISS)Social Care (PIAISS)
Interdepartamental Plan for Health andInterdepartamental Plan for Health and
Social Care (PIAISS)Social Care (PIAISS)

PIAISS
 Integrated health and social care model.
 Started in 2014 with the participation of the Governmental Ministries:
Presidency, Health and Social Welfare.
 The aim is to guarantee a comprehensive health and social care service
for the 8-10% of the population who have social and healthcare needs.

Inductors of model changes
Home as the hub for delivery care
Co-responsibility of patients and families
Reduce insitutionalization

Without
33%
CD simple or
multiple
62%
CCP
3,5%
ACD
1,5% EoL
PREVENTIVE CARE
CURATIVE CARE PALLIATIVE CARE
PATIENT AUTONOMY
TEAM COORDINATION
Source: Blay C. PPAC, 2012
PPAC: CCP (Chronic Complex Patients) and ACD
(Advanced Chronic Disease) Concepts

New Model for Patient Empowerment: e-mail/ enter data/ access to educational
materials / outpatient and domiciliary request, etc...
New Ways of Interacting with the Patient

Indicators Primary
Healthcare
Hospital
Care
Avoidable Hospitalizations ++ ++
Homecare Programme Coverage ++ -
Health Outcomes: Good Control, Procedure
and Treatment
++ ++
Re-admission Rates in Chronic
Processes:COPD and Heart Failure
++ +++
“Urgent” or “Unscheduled” Hospitalization
Rate in COPD and Heart Failure Patients
++ ++
Discharge Planning in PRE-DISCHARGE
(PREALT) Programme
++ -
Ensuring Care Continuity in POST-
DISCHARGE Programme
- ++
“Quality of Life” Rating ++ ++
Transversal First - Second Level Indicators

• Re-inforce nursing care services portfolio in primary healthcare: support for
COPD and Heart Failure procedures, streamline others (Diabetes, Hypertension,
etc.).
• Develop specialized and varied nursing care programmes for chronic patients at
high risk: CCP/ACD
• Develop and lead case management programmes
• Design and formulation of Individual Care Plans
• Re-inforce Discharge Planning Strategies to ensure the “continuum of care” for
patients with an objective risk of re-admission.
• Re-inforce Homecare within the Social Services (chronicity and dependence)
• Organize facilities with capacity to respond to complex chronic patients in
situations of crisis and exacerbation, during night shifts and weekend shifts
(24h/7 service)
Reinforcement and Role Changes for nurses

• Reinforce proactive tele-care services
• Promote self-care in order to facilitate co-responsibility between patients and
carers throughout the care process.
• Improved treatment adherence
• Special interest in children with obesity and childhood asthma.
• Prevention activities and promotion of healthcare.
Reinforcement and Role Changes for nurses

26
PPAC & PIAISS Strategic Lines 2017-2020

27
1. Population Identification Status
2. Individual Intervention Plan Implementation Status
3. Mental Health Identification
4. Geriatric and Palliative Care (PC) Identification
5. Care Model for Children and Adolescents at End-of-life
6. Complex Care Pathways

28
The PIIC (Individual Intervention
Plan) is a common and updated
document, accessible on-line for
every health provider,
containing...

29
WHAT IS THE PROBLEM?
WHAT TO TAKE?
WHAT TO DO IF…?
5 LEVELS OF ACTIVATION:
Telephone, Immediate attention in home or health
center, Differed & Scheduled attention,
Intermediate Care, Acute Hospitals

Prevalence of patients with a well-filled PIIC
Source: Catsalut, 30th September 2016
Objective 2017
Barcelona Health Region: Good PIICs (Individual Intervention
Plan)

Prevalence among people with good PIIC
Source: Catsalut, 31st December 2015
PIICs (Individual Intervention Plans) with good, bad o without
completion in Catalonia

Where to Begin?Where to Begin?Where to Begin?Where to Begin?
Primary care and Community ProgrammesPrimary care and Community ProgrammesPrimary care and Community ProgrammesPrimary care and Community Programmes
TheThe ““DeconstructionDeconstruction”” of Hospitalsof HospitalsTheThe ““DeconstructionDeconstruction”” of Hospitalsof Hospitals
ConclusionsConclusionsConclusionsConclusions

Primary Health Care and Community Programmes
Inter-ministerial Public HealthInter-ministerial Public Health
Programme (PINSAP)Programme (PINSAP)
Inter-ministerial Public HealthInter-ministerial Public Health
Programme (PINSAP)Programme (PINSAP)
Community Health ProgrammeCommunity Health Programme
(COM Salut)(COM Salut)
Community Health ProgrammeCommunity Health Programme
(COM Salut)(COM Salut)
National Primary and CommunityNational Primary and Community
Healthcare Strategy (ENAPISC)Healthcare Strategy (ENAPISC)
National Primary and CommunityNational Primary and Community
Healthcare Strategy (ENAPISC)Healthcare Strategy (ENAPISC)
https://www.youtube.com/watch?v=D2iHpdj0DcI

COM Salut
Started 2002
BAH (Basic Area of Health) of 10,121
inhabitants
1 Primary Health Care Team
1 City Council Health Technician
A space for
women health
Physical activity and sport

Primary Care
 The primary healthcare network is the first level of care and serves
as the main point of access.
 The area is organized on the basis of Basic Areas of Health (BAH),
each one being the operation area for the Primary HealthCare Team
(PHCT) assigned to a reference population. Catalonia is currently
divided into 369 BAH.
 99.94% of the total population registered as residents in Catalonia
had an assigned PHCT in 2017.
 Children under two years of age are 2.81% of the total population
and the 75+ age group represents 8.97% of the total population
(these are the two groups with more outpatient visits in primary
care).

Primary Care – continuous monitoring of outputs & outcomes
Adequacy

Primary Care
Pharmaceutical Prescription - Medications

Primary Care
Homecare (% of population over 64 years with domiciliary visits)

Primary Care
Chronic Disease Control

Primary Care
Cost of Medication

Primary Care
“Essential” project: adding value to clinical practice
http://observatorisalut.gencat.cat/ca/central_de_resultats/

An Example in a district of Barcelona City:
Nou Barris
CSC - Consorci de Salut i Social de Catalunya
(Catalan Health and Social Care Consortium)
April 2017

Integrated Homecare of chronic complex patients
Entrance Point and Unique Provisions:

1. Integrated Homecare of complex chronic patients
Tracking Indicators: Information Shared with Social Services:

Social Care: Health Care:
-- Strengthen the family and community support network
-Support and training of patients and families
- Bank of technical assistance utilities
-Occupational therapy
-Mental Health support
- Support group, cs for carers
- Household cleaning and maintenance
- Functional adaptation of homes
- Direct assistance in activities of daily
living
- Home delivery of meals
- Activation/deactivation of telecare
- Social support and education
- Healthcare: diagnosis, care plan
- Physiotherapy
- Prevention guidelines
- Psychological support
- Chiropody (supplementary)
- Odontology (supplementary)
47

Making hospitals smaller
EESRI 2008.
Rechel B. Investing in hospitals of the future. 2009

Costs of subacute and long-term care Health services in Catalonia,
2002-12
% Total Healthcare
Cost
Social Healthcare
Service Costs
Source: Central de resultats, Catsalut, 2013

Cost of Patients in their Last Year of Life (Hospital Death)
January 2005 – March 2012:
- 5,125 patients
- Consumption in 2 Previous Years
Asssitencial Health Evalutation Area. SAGESSA Group, 2012. With permission

Reduce the Use of Hospitals
Need to Share Costs with community
Carers to be more involved
Inductors of model changes

HomeHomeHomeHome
HospitalHospitalHospitalHospital
Nursing homeNursing homeNursing homeNursing home
1. SHOULD NOT COME TO HOSPITAL
2. IF DO COME, SHOULD NOT BE ADMITTED
3. IF ADMITTED, SHOULD LEAVE QUICKLY
Old Patients with chronic conditions

Hospital Services for Complex Patients
Acute Medical and Surgical Care Units
In-hospital programmes to reduce risk (falls, delirium,…)
Rehabilitation and Recovery Units
Home Hospitalization
Re-design Accident & Emergency departments
Nursing Home Care

Acute Medical and Surgical Care Units
In-hospital programmes to reduce risk (falls, delirium,…)
Rehabilitation and Recovery Units
Home Hospitalization
Re-design Accident & Emergency departments
Nursing Home Care
Hospital Services for Complex Patients

Post-Acute Care
Acute Rehabilitation
Days admitted
Acute
Rehabilitation
Days admitted

Subacute Units
Acute Rehabilitation
Acute Subacute
Home
Rehabilitation
Days admitted
Days admitted

First Data Showing the Functioning
Conditions of Subacute Units in Catalonia as
an Alternative to Conventional Hospitalization
Case study analysis and results from the implementation of subacute
programmes in 10 centers in Catalonia
Observatory of alternatives to hospitalization
May 2016
Segueix-nos al twitter!
@CSC_Consorci

Subacute Units in Catalonia (I)
1.Centre accreditation requirements
• Skilled nursing facilities linked to acute hospitals (Permeable circuits for patients
and professionals)
• Regional acute hospitals
2.Specific standards for subacute healthcare
 Interdisciplinary team with 24h medical care.
 24 h access, 365 days a year.
 Capacity for intensive rehabilitation.
 Laboratory (blood, urine and blood gas analysis), pulsioximetry, ECG,
emergency and scheduled X-rays.
 Oxygen therapy, intravenous therapy, scheduled transfusions.
 Accessibility to inter-consultation for other specializations in the same center
 Access to programmed testing (ultrasound, CT, MRI).
 Quick access to acute reference hospital.

Subacute Units in Catalonia (II)
¿Which patients are candidates for subacute care?
Chronic complex patients with exacerbation that requires short term hospital admission,
hemodynamically stable, and don't require high technology or need to be attended at
home.
Catalonian Department of Health outcome indicators and standards
- Mean Length of Stay (LOS) ≤ 12 days
- Return to home ≥ 70%
- Mortality ≤ 10%
- Referral to acute hospitals < 10%
- Referral to other intermediate care resources < 15%
- Admission from: A & E Department 80%









11










Participating Centers in the Study: Number of Cases 2014
n
2015
n
28 50
- 33
42 27
70 50
58 87
56 111
17 145
62 48
84 46
12 68
63 71
492 736
Total
1
1

Results (I)
Patients characteristics
2014 2015
Age, Years (DE) 84.2 (7.2) 85.9 (7.2)
Men % 44.11 36
CCP/ACD Condition
CCP%
ACD%
No CCP/ACD%
37.20
10.77
52.03
35
11
53.8
Functional Status (Barthel Index) (DE) 56.4 (29.17) 49.43 (32.8)
Prevalence of Dementia % 43 40.4
Main Condition
Respiratory Diseases %
Cardiovascular Disorders %
37.6
23.4
55.8
20.1

Results (II)
Outputs & outcomes
2014 2015
Mean Length of Stay (LOS) (DE) 10.93 (7.27) 9.65 (5.73)
Admission from A & E Department(%) 73.16 84
Destination(%) Standards
Home >70%
(Residence)
Death ≤ 10%
Acute Hospital Referral< 10%
Intermediate Care Referral< 15%
71.34
(11.99)
13.82
6.10
8.74
64.3
(14.4)
16
3.5
16.2

Results (III)
Functional status at discharge, re-admission and 30 days
maortality after discharge
2014 2015
Barthel Discharge Operational Status (DE)
Barthel Difference
56.5 (27.65)
+0.1 (15.9)
40.94 (33.58)
-8.49 (20.52)
30 Day Analysis
Barthel
Re-admission %
Death %
n= 230
58.07
19.1
11.3
n= 508
45.5
20.5
18.9

Conclusions
1.Very frail patient profiles (multiple conditions, disability and dementia).
2.Partially meet pre-established standards:
• Deviations: Mortality (in accordance with the profile of patients)
• Good functioning of ALOS (Average Length of Stay) and destination at discharge
3.Moderate functional loss at discharge, with high re-admission and 30 day mortality rates.
4.This type of unit acts as a real alternative to acute hospitalization, always with an
adequate selection of patients.

Intervention in Nursing Homes
Díaz-Gegúndez M. Evaluación de un programa de intervención en residencias geriátricas para reducir la frecuentación
hospitalaria. Rev Esp de geriatr y gerontol, 2011

Reflections for Action
 Re-inforce primary care as the main actor of healthcare
system:
 From “gatekeeper” to service provision
 Strengthening of team work and role changes in nurses
 Orientation and stimulation towards the integration of social
and community services
 Re-think hospitals in order to attend these patients:
 Organization by complexity and not by medical specialty
 Transfer some parts of care to alternative units to
hospitalization (day hospitals, home hospitalization, skilled
nursing facilities, etc.)
 Reinforce post-acute and subacute units
 Integration

jagarcia@consorci.org
consorci@consorci.org

Chronic Disease Management: tools for balancing an increasing expenditure and a limited budget…with well-cared patients - José Augusto García Navarro

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