A journey from the Chronic Condition Care Program to a new health and social integrated care model. Deck available in link: http://www-01.ibm.com/software/city-operations/curam-research-institute/curam-roundtable/index.html

1. A journey from the Chronic Condition
Care Program to a new health and
social integrated care model.

2. 2
4 Provinces / 41 Counties / Districts) /
947 Municipalities (64 with more than 20.000 hab)
Territorial Structure of Catalonia

3. Source: IDESCAT, 2015
Ageing in Catalonia 2013-2051
In 2050:
1/3 over 65 y.
>12% over 80y.

4. Total population: 7,49 million in 2013 and 7,95 million in2051
Elderly projection:
• > 65 y.: 1,30 million in 2013 and 2,45 million in 2051
• > 80 y.: 0,41 million in 2013 and 0,94 million in 2051
• Centenarians: 1.700 in 2013 and 21.600 in 2051
Life expectancy at 65 years:
Men: 18,7 in 2012 and 22,6 in 2050 (4-year increment)
Women: 22,7 in 2012 and 26,5 in 2050 (4-year increment)
Life expectancy at birth:
Men: 80 in 2015 and 85,33 in 2050 (5-year increment)
Women: 85,6 in 2015 and 90,21 in 2050 (5-year increment)
Population projection 2013-2051
Source: IDESCAT, 2015

5. Healthcare System
• Basic decentralization to regional autonomies
according with a basic Spanish law.
• Universal coverage
• Free access
• Wide range of publicly covered services
• Services provided mainly in public facilities
• Funded by taxes
• Co-payment in pharmaceutical products
• Interterritorial Board to coordinate policies
5

6. Social Service System
• 100% decentralization to regional governments except for the
dependency system
• Significant decentralization to the local
governments of the basic social services
• Funded by taxes but with significant
Co-payment for most of the specialized
services.
• Universal coverage but not free access to the services.
• Basic social services publicly covered but specialized
services not entirely publicly covered
• Services provided in public facilities, private providers and
third sector.
• Interterritorial Board to coordinate policies
6

7. Catalan Healthcare System: some basic features
• Ministry of Health: annual budget of 8,500 million Euros.
• 369 Primary Healthcare Centres (PHC) ranging from 20-45,000 inh.)
• 69 “acute hospitals” (no far from 50 Km. from every home)
• 96 “health long term & intermediate care” centres (long-stay, convalescence,
palliative care – 5,557 publicly funded users)
• 41 Mental Health Centres
Catalan Social Service System: some basic features
• Ministry of Social Welfare and Family: annual budget of 1,500 million Euros +
extra expenditure from Local authorities.
• 106 Basic social services Areas run by local governments (min. 20,000 inh)
• 48,173 publicly funded users for residential care (including residential homes,
supervised housing and health long term care for elderly, disability, mental health
and children).
• 19,287 publicly funded users for daily care.
7
Different maps of service delivery areas

8. Chronic Condition Care Program
2011
1

9. Source: Catalan Health Plan 2011-2015.
Health Programs:
Better health and quality
of life for everyone
Transformation of the care
models: better quality,
accessibility and safety in
health procedures
Modernisation of the
organisational models: a
more solid and sustainable
health system
I
II
III
For each line of action, a series of strategic projects will be developed, which make up the
31 strategic projects of the Health Plan.
9. Improvements to information, transparency and evaluation
1. Objectives and health programs
7. Incorporation of professional and clinical knowledge
6. New model for contracting health care
5. Greater focus on the patients and families
8. Improvement of the government and participation in the system
2. System
more
oriented
towards
chronic
patients
3. A more
responsive
system
from the
first levels
4. System with
better quality
in high-level
specialties
The Catalan Health Plan 2011 - 2015

10. 2.1 Integrated clinical processes
2.2 Protection, promotion and prevention
2.3 Co-responsibility and self-care
2.4 Alternatives in an integrated system
2.5 Complex chronic patients
2.6 Rational prescription and use of drugs
Strategic lines Chronic Condition Care Program
AllstrategiclinesrequireICT
toolsanddevelopments

11. Documents
published per
year
23.097.493
• 2.119.605Average documents published per month
• 92.262.770Indexed documents
• 6.704.591Patients with reports
Shared Clinical Record (HC3)

12. PCC
Multimorbidity
Severe unique
disease
Advanced frailty
MACA
Limited live
prognosis Palliative
approach, Advance
care planning
12
Labeling two profiles of complexity
-Care centres that have patients
classified and marked in these two
types, can publish this label/mark in
HC3
- The classification / label must be
visible on all the screens , given the
importance of the condition
PCC: Complex Chronic Patient
MACA: Advanced chronic
disease

13. 9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target:
25,000 complex
chronic patients
should be identified by
2015
In January 2015 over
120,000 patients
included
Evolution in number of PCC and MACA:
“Labeling” available since January 2013

14. Guarantying a basic health assessment in Complex Chronic Patients
• Basic standardized and customized assessment: Functional + Cognitive
impairment + Social Risk + Depression
• NECPAL assessment to identify “Advanced Chronic Disease” condition
• Complementary assessment
Challenge:
To construct a shared and
joint Assessment and
Intervention Plan

15. Ensuring a “Health shared Individual Intervention Plan” for all pcc
Health problems/Diagnosis
Active Medication
Allergies
Recommendations for “in case of
crisis” or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest

16. WARNINGS and ALERTS
Discharge Planning
Challenge:
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing “Transional
care” with Primary Health
Care and Social Services (in
short time)

17. Defining a stratification model. Population based
CRG RSC
Identification people at
risc
Proactive measures
Classification people at
risk
Segmentation for the
proactive management
of people at risk
Identification and
recording at Clinical
Record
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk

18. CMBS (minimum data set): unified data base data sources
Insured data source
NIA, demographic data
Diagnosis data base
NIA, tipus_codi, codi, data dx ,UP,
tipus_UP
“Contact” data base
NIA, dates contacte ,UP, tipus_UP,
urgent, CatSalut, T_act.
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-A&E
Central Registered
Insured
Health Problems
Pharmacy (PHC
and hospital
provided)
Pharmacy data base
NIA, ATC, data dispensació, unitats,
Import
Mortalitat (INE)
Divisió d’Anàlisi de la Demanda
i de l’Activitat 18

19. Clinical Risk Groups and levels of aggregation
Standard aggregation  1.000 groups (CRG) Aggregation in groups
St. 9: High need
condition
St. 8: Severe neopl
St. 7: Chronic cond. 3
or more organs
St.. 6: Chronic cond.
2 organs
St. 5: Chronic condit.
St 4: Minor chronic
cond. diff. organs
St. 3: Minor chronic
cond.
St. 2: Acute condition
St. 1: Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
In the standard aggregation (health status, basic
CRG and level of severity) we obtain a basic
information about health status and level of
severity in less than 40 groups
HealthStatus
Severity Level
Status 9
Status 8
Status 7
Status 6
Status 5
Status 4
Status 3
Status 2
Status 1
1 2 3 4 5 6
More than 1,000 groups. Too
much !!!

20. New “panel management” introduced
•It has been converted information
into warnings when we access to
clinical record in each visit
•Customized configuration per
professional and team
•Warnings sorted by importance and
relevance
•Weekly calculation
•“Front-office” and “back office”
modality
Mean 20-30% improvement in some scores!

21. Multimorbidity in Catalonia obtained by stratification
Challenge:
It is required to
include
“social data”
to adjust
stratification

22. Prevalence of multimorbidity
Information available at regional and PHC level

23. 1% 18% 133% 10.992€ 13% 13%
2% 7% 57% 5.872€ 13% 26%
8% 3% 28% 3.162€ 28% 54%
17% 1% 14% 1.411€ 25% 79%
72% 0% 2% 282€ 21% 100%
POPULATION MORTALITY
TAX
HOSPITALI-
ZATION TAX
ESTIMATED
EXPENSE
% ACCUMU-
LATED
Impact distribution of different segments:

24. Who are the PCC and MACA patients ?
Source: CatSalut, 2013
PCC MACA

25. Who are the PCC and MACA patients ?
Source: CatSalut, 2013
Distribution of emergency admissions
1 chronic
condition
2 chronic
conditions
3 chronic c.
Cancer Other high
demanding c.

26. Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes: good control,
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPD/HF Avoidable Hospital
Admission
++ ++
Discharge planning in “PRE-
Discharge” program
++ - -
To ensure continuity care in “POST-
Discharge” program
- ++ ++
“Quality of life” (HRQoL) assessment ++ ++ ++
Challenge:
To aggregate health and social
care data

27. Expert assessment quality measure related to Chronic Care:
final selection of 25-30 indicators
Importance/relevance for management
Importance/relevance for clinicians
Importance/relevance for citizens
Feasibility: data available?
Generating “clinical integration”

28. • Indicators of admissions for every Sector and Primary Health Team
• 14 chronic diseases
• Benchmarking with different standards among PHT and Hospitals
Servei Català Salut. División de Registros
Using quality measures. MSIQ
MSIQ: http://146.219.25.61/msiq/index.html

29. Hospital admission by diagnostic groups > 70 y.
0 4000 8000 12000 16000
Hipertensió essencial
Deliri, demència i altres trastorns cognitius i
amnèsics
Trastorns del metabolisme hidroelectrolític
Asma
Infeccions i ulcera crònica pell
Diabetis mellitus amb complicacions
Hipertensió amb complicacions i hipertensió
secundària
Pneumònia per aspiració d'aliments o vòmits
Infeccions de vies urinàries
Pneumònia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crònica i bronquièctasi
Insuficiència cardíaca congestiva
70 and more
Pneumonia
Source: DGPRS. Dep Salut, 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications

30. Large differences in emergency hospital admission rates by
sector (x 100.000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average: 971 x 100.000 inh.

31. Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average: 10,78%

32. Hospital admissions for chronic conditions
Monthly udpated information!
Includes: COPD, HF, DM complications, asthma, coronary diseases, HTA
Availability of evolution of avoidable emergency admissions for
a range of chronic conditions per region / sector / PHC team
(x 100.000 inhab. Tax)
Source: MSIQ, Catsalut
−8 %
last 24
months
709,6
684,1
652,7
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013

33. Potentially avoidable hospital admissions for COPD
Decrease by 13,1 % from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per
region / sector / PHC team (x 100.000 inhab. Tax)
Source: MSIQ, Catsalut

34. Potentially avoidable hospital admissions for heart failure
Source: MSIQ, CatSalut
Decrease by 3 % from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of Avoidable Emergency admissions per Region /
Sector / PHC Team (x 100.000 inhab. Tax)
trend
Increase by 25%
from 2006 till 2011

35. Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100.000 inhab.)

36. More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation

37. Variability Atlas related to indicators
Source:Evaluation and Quality Agency
Population based related to
Primary care area

38. Implementing integrated care pathways (within the health system)
• Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
• Based on reference clinical guidelines and best evidence practice
• 80% of territories implemented 3 of 4 chronic conditions: COPD, depression, heart
failure and DM2. Now Complex Cronic Care Pathways work
• Agreement on different “situations”: 0. Diagnosis, 1. Stable, 2. Acute exacerbation, 3.
Management difficulty, 4. Transitional Care. Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care

39. Check list for support of deployment complexity care model:
Basic and Priority: “PCC” and “MACA” identification and
labelling + Integrated Care Pathway + 24 / 7 model +
Carer identification and support

40. Changing the contract 2013 with common PHC-Hospital Targets
40
COMMON TRANSVERSAL OBJECTIVES(20%)
Reduction Avoidable Hospital Admissions Rate (composite, HF and COPD)
Reduction 30-day Readmission Rate for HF and COPD (also composite)
Get minimum value prescription pharmaceutical index
% minimum discharges with contact before 48 hours after discharge
% minimum register screening risk factors Metabolic syndrome TMS
ESPECIFIC TRANSVERSE OBJECTIVES (“TERRITORY”) (20%)
% minimum PCC/MACA with Intervention Plan (“PIIC”)
% minimum PCC/MACA with medication review
% minimum PCC/MACA with post-discharge medication conciliation
Reduction emergency admissions in PCC/MACA
Minimum number participants Expert Patient Program
% minimum COPD patients with spirometry
% minimum PHC with Mental Health integration
Prevalence minimum depresion with “severity” criteria
% minimum patients with depresion with “suicide risk” assessment
Development at local level a consultant virtual office
“Amputation rate” reduction in DM
“Ophthalmology/locomotor “ referral first visits under expected tax

41. 41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a “Health shared Individual Intervention Plan” for all pcc
Defining a stratification model. Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures. MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care

42. 42
2014. A step forward to a model of health and social
integrated care
2

43. 3 September 2013:
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013:
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014:
New Government Agreement for the
creation of the PIAISS

44. Inter-ministerial Social and Health Care and Interaction Plan
44
Mission: Promote and participate in the transformation of the
health and social care model with the aim of ensuring an
integrated, people-based care that responds to their needs.
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry, the Ministry of Social Welfare and
Family and the Ministry of Health.
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs.

45.  Contribute to maintain the level of health and social welfare results /
outcomes for the target population.
 Improve perception of quality on the experience of care to the health
and social needs for the target population
 Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources.
 Guarantee a planed, proactive, personalized, co-ordinated and
adapted to the individual health and social care needs, improving the
quality of care and increasing the co-responsability and empowerment
of the person.
Integrated care, why?
45

46. Integrated Care, for who?
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC
Multimorbidity
Severe unique disease
Advanced frailty
MACA
Limited live prognosis
Palliative approach,
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs

47. For us complexity has to do with...
50
RELATED WITH MORBIDITY
UNCERTANLY: It is difficult to predict what
is the best decision
MULTIMORBIDITY: accumulation of
problems you have to manage and decide
about.
INSTABILITY: The difficulty of finding an
equilibrium state
GRAVITY: Intensity that the problem is
manifested.
PROGRESSION: Speed with which the
situation can deteriorate.
RELATED WITH THE PROFESSIONALS
MULTIPLICITY: many actors involved in the
decision making.
LACK OF AGREEMENT: experts may not
agree on the recommendation.
RELATED WITH THE PERSON
FRAILTY: Low personal resilience.
IMBALANCE: From an area that can
decompensate other.
ANOSOGNOSIS: lack of awareness of the
problem
NO VOLITION: low/zero collaborative attitude
about the need of change despite this awareness
QUALITY OF THE NETWORK: relational,
community, family support.
RELATED WITH THE SYSTEM
FRAGMENTATION: professional, organizations
and services fragmented.
NO ABAILABILITY OF THE INDICATED RESOURCE
Font: Elaboració pròpia del PPAC i PIAISS: Blay, C. Ledesma, A. Contel, J.C. González, C. Sarquella, E. Viguera, Ll. I aportacions de Varea, J.A.

48. Integrated health and social care: shared approach
Multiple front door (mainly at Prim.
care). Unique response
Implementation (efectiveness,
coordination, multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring, evaluation and
feedback
Identification and registering (in the
community)
Casemanagement
/Sharedcare

49. Catalan Model of Health and Social Integrated Care. Core & enabling elements
“Microsystems”
•Community-based and
primary care leadership
•Integrated care pathways
•Multiprofessional work
•Transitional care
•Out of hours care
•Home care strategies
Joint case / care load. Shared
needs assessment + action plan
Stratification models:
assessing population needs
Clinical and professional
leadership
Health and social care
local Partnerships
Shared outcome framework :
shared responsibility & joined
accountability
Shared vision about the
use of resources:
Aligned Incentives
Shared Electronic Health
and Social record
Person Empowerment
and Self-care
ENABLING ELEMENTS
Multi-lever approach: ALL things at the same time
Culture and change
management

50. Build Plane In The Air http://youtu.be/M3hge6Bx-4w
Projects and actions

51. Font: Elaboració pròpia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities
Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care & telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors:
Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition

52. Hospitals
Integrated Care: more than multi-level health care integration
www.flaticon.com (1)
www.freepik.com (1) (2)
www.morguefile.com
COMMUNITY
HEALTH AND SOCIAL
PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4: Local partnerships implementation

53. 57
Reus
Lleida
Salt – Gironès
Alt Penedès: Vilafranca i comarca
Mataró
Vilanova i la Geltrú
La Garrotxa: Olot i comarca
La Cerdanya: Puigcerdà i comarca (en procés)
Alta Ribagorça: El Pont de Suert i comarca (en procés)
Baix Llobregat: Gavà, Viladecans, Sant Boi i Cornellà (inicial)
Vallès Oriental: Granollers, Les Franqueses i Canovelles (inicial)
Osona: Vic, Manlleu, Mancomunitat la Plana i comarca (inici)
Terres de l’Ebre (inici imminent)
2 districtes de Barcelona ciutat: Besós i Esquerra de l’Eixample
Sabadell
Local partnerships
working now:

54. 58
Pilot project with Barcelona city council
 Objectives
The main purpose is to build a framework to improve the interaction
between social and health services.
It wants to define a model to share information between both services
replicable to other entities in Catalonia.
This project wants to promote continuity of people attendance, by using
information and communication technologies (ICT).
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure

55. 59
Legal framework
 REGULATIONS IDENTIFICATION
 AGREEMENT
The “Framework agreement" has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC
(Shared Medical History of Catalonia) and Social Service Information System of
Barcelona.
 CONSENT
Informed consent to ask the citizen authorization to share their health and social
information.
 PERSONAL IDENTIFICATION NUMBER
The “Personal Identification Number” has been established as the common
identifier in health and social systems.

56. Health and social information sharing
60
Category
HCCC (Shared Medical History of
Catalonia)
SIAS (Social Service Information System of
Barcelona)
ID
information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
E-mail
Census
Services
information
Professionals
(general practitioner, nurse)
Health centre, palliative care, home care,
nursing homes...
Professional (social worker)
Social services centre
Supplementar
y information
Economic information: pharmaceutical copayment
Legal incapacity: process, date, guardian
Health
information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability: recognized level, kind of disability,
disable scale.
Dependent people: recognized level.
Risk alert (coronary heart disease, fall s...)
Needs
assessment
Barthel ADL index
Lawton-Brody's index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brody's index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a
Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours
before)
Medical discharge documents
A&E documents
EMS (emergency medical services )documents
Services:
 Home care services
 Telecare
 Food assistance
 Day care centres
Community
care
Programs/projects Programs/projects

57. The social data domain
 Is an open domain of the Clinical Dictionary
that includes:
 Types of service.
 Status of requests.
 Scales of evaluation.
 Environment devices.
 Social diagnosis (problems).
 We are mapping all this concepts to
SNOMED CT in order to obtain a semantic
standard:
 That guarantees the exchange the
information from different sources
without losing its meaning:
 And allows us to uniquely identify,
represent, compare, translate and
exploit it.

58. 62
ICT infrastructure
The project wants to build a framework to improve
the interaction between social and health services,
by using information and communication technologies
(ICT). Moreover It focuses on person-centered care.
This model exchange take the health technical
model as a reference.
Web Services are used for providing structured
information and to make easier the integration of
the workstations in the health and social centers.
 The health professionals can view social
information requested of a citizen.
 The social professionals can view health
information requested of a citizen.

59. A Web Service is a method of communication between two electronic
devices over a network. This will be the way to share information between
HCCC (Shared Medical History of Catalonia) and SIAS (Social Service
Information System of Barcelona).
Technological terms
Security Common repository
 Informed consent will be signed by
the citizen.
 The health or social professional will
send the document to the common
repository .
 Each professional can check if the
citizen has signed this consent.
 Informed consent will be custodied
in a common repository.
 It will be validated by both systems.
 It will do periodic checks.
Send
informed
consent
and check
Health Departament
Information System
Social Service
Information System

60. 65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle. Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy & Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons:

61. Implementing community-based
integrated care in practice
Towards a collaborative model of integrated care in Tona

62. gencat.cat