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Patient Empowerment from an Integrated Care Approach

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In a context of growing incidence of chronic diseases and ageing populations, there is the need to research and find new solutions to shift resources into the community in an effort to deal more effectively with chronic conditions. In that direction, patient empowerment plays an important role. Approaches to increase patient empowerment vary from patient self-management programs, to promoting patient involvement in treatment shared decision-making, to facilitating the clinician-patient cooperation. This talk focuses on self-management as a way to engage and empower patients in order to improve their quality a life and to allow a better follow-up by clinicians. A practical example from the CONNECARE project will show how self-management could be put in practice for supporting complex chronic patients.

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Patient Empowerment from an Integrated Care Approach

  1. 1. Patient Empowerment from an Integrated Care Perspective Eloisa Vargiu eloisa.vargiu@eurecat.org Source: https://biopsy.wordpress.com/2009/04/06/patient-empowerment/ 1st Edition COMP-MED: Computational Methods in Translational Medicine
  2. 2. 1st Edition COMP-MED: Computational Methods in Translational Medicine 2 Source: https://www.floptv.tv/flog/la-nuda-verita/pensionato-fugge-dalla-casa-di-riposo-per-fissare-un-cantiere/ The Context
  3. 3. 31st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Ageing Population An ageing population and the increasing number of people with at least one chronic disease are demanding more resources and increasing the burden on health and social care systems
  4. 4. 41st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Chronic Patients Source: https://health.usnews.com/health-news/health-insurance/articles/2015-12-23/how-to-get-the-best-plan-when-you-have-a-chronic-illness Chronic diseases are the leading cause of mortality and morbidity in Europe, the major cause of disability, the principle reason why patients visit physicians, and the reason for 70% of health care expenditures
  5. 5. 51st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Complex Chronic Patients  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
  6. 6. 61st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Complex Chronic Patients  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
  7. 7. 1st Edition COMP-MED: Computational Methods in Translational Medicine 7 Photo Credit: photoloni | Flickr Effects and Underlying Problems
  8. 8. 81st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Increasing of Health Costs  Movements from home to hospital/medical facilities  Number of (re)-hospitalizations  High resources in terms of professionals involved Quality of Life Worsening  Patients, familiars, and caregivers frustration  Anxiety, depression, and mental disorders  Loss of confidence in the health system  Waste of time
  9. 9. 91st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Lack of Coordination
  10. 10. 111st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Lack of Coordination in Practice Source: https://www.connecare.eu/
  11. 11. 1st Edition COMP-MED: Computational Methods in Translational Medicine 12 The Goal
  12. 12. 131st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) The Goal understanding by the patient of her/his role acquisition by patients of sufficient knowledge to be able to engage with their healthcare provider(s) patient skills the presence of a facilitating environment Empowerment
  13. 13. 141st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Patient Empowerment A process through which people gain greater control over decisions and actions affecting their health
  14. 14. 1st Edition COMP-MED: Computational Methods in Translational Medicine 15 The Way
  15. 15. 161st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Integrated Care  Integrated care models are designed to respond to the effects and problems listed before  The defragmentation of health and social care systems  The promotion of collaboration and continuity among care settings  A move from institutional, reactive care to a home- based, patient-centred, preventive model INTEGRATED CARE Enhancing the value of care Cost efficiency Efficiency and outcomes improveme nt User Experience
  16. 16. 171st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What is Integrated Care? References/sources: Lewis R, Rosen R, Goodwin N, Dixon J. Where next for integrated care organizations in the English NHS? London: The King’s Fund; 2010. Fulop N, Mowlem A and Edwards N (2005) Building Integrated Care: Lessons from the UK and elsewhere. London: The NHS Confederation.
  17. 17. 181st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) The Chronic Care Model Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
  18. 18. 191st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Evidence on Effectiveness of the Chronic Care Model References/sources: Zwar, N., Harris, M., Griffiths, R. et al. (2006) A Systematic Review of Chronic Disease Management. Sydney: Australian Primary Health Care Institute. Wagner EH. Care of older people with chronic illness. Older People Build Syst Ased Evid. 1999;39–64
  19. 19. 1st Edition COMP-MED: Computational Methods in Translational Medicine 20 The Tools
  20. 20. 211st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Patient-centred Care A way of thinking and doing things that sees the people using health and social services as equal partners in planning, developing and monitoring care to make sure it meets their needs
  21. 21. 221st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Co-Design Requirements gathering Patient- centered evaluation Final deployment
  22. 22. 231st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Stimulate Active Participation Facilitating new forms of active participation by patients and consumers in the collection of personal health data will improve the quality of care delivered to patients through better diagnoses and targeted therapies Source: https://velvetchainsaw.com/2010/04/14/stomaching-long-conference-lectures-is-out-active-attendee-participation-is-in/
  23. 23. 1st Edition COMP-MED: Computational Methods in Translational Medicine 24 Patient Empowerment
  24. 24. 251st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Strategies patient self- management programs promoting patient involvement in treatment decision- making facilitating the physician- patient interaction
  25. 25. 261st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Evidence on Effectiveness of the Chronic Care Model References/sources: Zwar, N., Harris, M., Griffiths, R. et al. (2006) A Systematic Review of Chronic Disease Management. Sydney: Australian Primary Health Care Institute. Wagner EH. Care of older people with chronic illness. Older People Build Syst Ased Evid. 1999;39–64
  26. 26. 1st Edition COMP-MED: Computational Methods in Translational Medicine 27 Source: https://www.alliance-scotland.org.uk/blog/news/self-management-fund-review-2017/
  27. 27. 281st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Self-Management Source: http://www.phsa.ca/Documents/patientselfmanagementpatrickmcgowanbc.pdf The systematic provision of education and supportive interventions by health care staff to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support.
  28. 28. 291st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? maintaining exercises and activity levels monitoring physical indicators by objective means recognizing and responding to symptoms and controlling triggers to symptoms drug prescription and follow-up maintaining nutrition and dietary recommendations giving up smoking and drinking using strategies to relax and reduce stress managing emotions and psychological response to illness adapting to work/education interacting with healthcare professionals seeking information and using community resources managing relations with similar patients managing alerts and emergencies Ref: Clark, N.M., Becker, M.H., Janz, N.K., Lorig, K., Rakowski, W., Anderson, L.: Self-management of chronic disease by older adults: a review and questions for research. Journal of Aging and Health 3(1), 3-27 (1991)
  29. 29. 301st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? maintaining exercises and activity levels
  30. 30. 311st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? monitoring physical indicators by objective means
  31. 31. 321st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? recognizing and responding to symptoms and controlling triggers to symptoms
  32. 32. 331st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? drug prescription and follow-up
  33. 33. 341st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? maintaining nutrition and dietary recommendations
  34. 34. 351st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? giving up smoking and drinking
  35. 35. 361st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? using strategies to relax and reduce stress
  36. 36. 371st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? managing emotions and psychological response to illness
  37. 37. 381st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? adapting to work/education
  38. 38. 391st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? interacting with healthcare professionals
  39. 39. 401st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? managing alerts and emergencies
  40. 40. 411st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? seeking information and using community resources
  41. 41. 421st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) What a Patient Should Manage? managing relations with similar patients
  42. 42. 1st Edition COMP-MED: Computational Methods in Translational Medicine 43 How to Manage Everything?
  43. 43. 441st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Underlying Needs  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  A work plan agreed among primary care doctors and hospital staff (need of communication)  Preventive actions at ambulatory level
  44. 44. 451st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Use an Integrated Care Approach  Improvement of communication and information flow between primary care and hospital to work together  Remote monitoring of clinic variables and improvement of communication among the professional team and the patient to prevent acute situations “All together to anticipate problems”
  45. 45. 461st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Closed Loop Approach  Primary care doctors and hospital staff agree a work plan  The plan includes the list of tasks that the patient has to perform  Tasks consist on managing one or more of the listed variables  The patient self-manage her/his status  Professionals continuously monitoring patient’s status  Professionals may change the work plan accordingly  …
  46. 46. 471st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) An Integrated Care Solution
  47. 47. 1st Edition COMP-MED: Computational Methods in Translational Medicine 49 Open Issues
  48. 48. 501st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) How to Engage the Users? https://vimeo.com/128873380
  49. 49. 511st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Engagement vs Addiction
  50. 50. 1st Edition COMP-MED: Computational Methods in Translational Medicine 52
  51. 51. 531st Edition COMP-MED: Computational Methods in Translational Medicine Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org) Wrap-Up  Complex chronic patients require the 40% of the health budget  Right now coordination and communication among hospital staff, specialists, and primary care doctors is very fragmented  Patients has to be empowered to better manage their health status  Professionals at any level have to coordinate each other  A continuous and remote follow-up is needed  Quality of life must be improved!
  52. 52. GRÀCIES! ¡GRACIAS! GRAZIE! THANKS! info@eurecat.org www.eurecat.org www.twitter.com/eurecat_news www.facebook.com/Eurecatorg eloisa.vargiu@eurecat.org

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