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Connected Care for Complex Chronic Patients in Lleida

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Results from CONNECARE in Lleida (Catalonia)

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Connected Care for Complex Chronic Patients in Lleida

  1. 1. Connected Care for Complex Chronic Patients in Lleida Eloisa VARGIU, Juan Manuel FERNÀNDEZ, Felip MIRALLES Mireia Massip, Gerard TORRES Felix MICHEL, Florian MATTHES
  2. 2. Complex Chronic Patient • It is a clinical assistive concept • There is not a unified definition • Complex Chronic Patient (CCP): A person with a health and social care perceived quite difficult by the team of professionals in charge • Complex Chronic Patient (CCP): A patient with one or more chronic condition, with comorbidities or multimorbidities for causes • Intrinsic: clinic o dependent on the treatment adherence • Extrinsic: social and/or dwelling environment has several problems with high frequency and needs several resources 2
  3. 3. Complex Chronic Patient • 5% of the population • 40% of the health budget is devoted to give support to this kind of patients • 40% of the patients are in acute hospitalization 3
  4. 4. Complex Chronic Patient
  5. 5. Clinic or socio-familiar event When is the right moment to act?
  6. 6. Clinic or socio-familiar event Frail patient that does not start to consume resources, yet When is the right moment to act? 1 1
  7. 7. Clinic or socio-familiar event Frail patient that does not start to consume resources, yet At primary care: patient that has been already hospitalized at least once and go to primary care for a control When is the right moment to act? 1 1 2 2
  8. 8. Clinic or socio-familiar event Frail patient that does not start to consume resources, yet At primary care: patient that has been already hospitalized at least once and go to primary care for a control At the hospital: hospitalization of a patient that has already been hospitalized 1 or more times When is the right moment to act? 1 1 2 2 3 3
  9. 9. What CONNECARE is aimed to
  10. 10. • Risk stratification  Clinic validation o Comorbidity o Cognitive and emotional o Functional  Barrier identification o Therapeutic adherence o Self-care ability o Physic environment o Social environment Underlying needs • A work plan agreed among primary care doctors and hospital staff (need of communication) • Preventive actions at ambulatory level
  11. 11. 11 1. Improvement of communication and information flow between primary care and hospital to work together 2. Remote monitoring of clinic variables and improvement of communication among the professional team and the patient to prevent acute situations “All to one and better to anticipate problems” The CONNECARE solution
  12. 12. Hospital Information System Primary care Information System The CONNECARE solution
  13. 13. Case Identification Case Evaluation Work plan defined together and agreed by the parts Discharge The CONNECARE process
  14. 14. 14 The CONNECARE vision
  15. 15. Smart Adaptive Case Management 15
  16. 16. Smart Adaptive Case Management 16
  17. 17. Smart Adaptive Case Management 17
  18. 18. Smart Adaptive Case Management 18
  19. 19. Self-Management System 19 Health Status Physical Activity Simple Tasks Questionnaires Drugs Prescription
  20. 20. Self-Management System Profile / Settings Notifications Messages Advices Educational Material System Notifications Devices configuration
  21. 21. CONNECARE in Lleida 21 Population: ≈ 400k people Hospitals: Hospital Universitari Arnau de Vilanova (HUAV) Hospital Universitari de Santa Maria (HUSM) ≈ 500k office visits/year ≈ 14k admissions/year Primary Care: 23 Primary Care centres (12 of them 24h) 1 Primary Care emergency centre
  22. 22. CONNECARE in Lleida 22  28 patients;  50% women;  Median (min-max) age 84 (55-95)  Median (min-max) Charlson 7 (2-10);  Median (min-max) LACE 14 (9-19) Studies started on July 2018 in Lleida region focuses on integrated management of:  CS1 - CCP with medical worsening  CS2 - CCP undergoing surgical procedures Current situation:  1 case manager from the Hospital Santa Maria  31 hospital professionals  50 primary care professionals CS1  29 patients;  59% women;  Median (min-max) age 75 (56-86)  Median (min-max) Charlson 4 (1-9) CS2
  23. 23. CONNECARE @ICIC19 23 Poster 220 Poster 219 Poster 302 Overcoming Integration Failure Through Negotiation – A Workshop for Doers and Planners CONNECARE: A Bridge Over Troubled Waters Workshop Tuesday, April 2nd 14:00 – 15:30 5F
  24. 24. Thanks Gràcies This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 689802 Bedankt ‫תודה‬ Grazie Danke eloisa.vargiu@eurecat.org

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