Business Experience in Implementing an Advanced Telemonitoring Service. Valdivieso Martinez B. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

1. The Challenge:
“Improving Care Condition”
Dr. Bernardo Valdivieso Martinez,
Quality Manager & Planning Director
Department of Health La Fe, Valencia, Spain

2. Implementing an Advanced
Chronic Disease Management
Service
- Business Experience -

3. Sumary
The introduction
The problem
The solution
Lessons & learnt

4. An introduction
Spain Valencia land
Population: 4.396.318
> 65 years old: 17,3%
Health System:
Hospitals: 28
Primary Care Centres: 500
Budget: (million €)
3.074 (36,9%)

5. An introduction
Valencia land Health Department LA FE
• Atraction 52%
• Population: 260.000
• > 65 years old: 17,3%
• Health System
• Hospital: 1
• Primary Care Team: 13
• Budget (million €)
• 540 total
• 260 “capitation”

6. An introduction
Capitation
Concepts Expenses %
Personal costs 371.962.870,10 68,3%
Operating costs 110.761.052,67 20,4%
Arrendamientos 2.618.677,60 0,5%
Reparaciones 6.625.557,57 1,2%
Material oficina e informática 1.619.786,59 0,3%
Consumos energéticos, telefonía y ostales 9.416.549,05 1,7%
Vestuario y lencería 370.835,45 0,1%
Ptos. Farmacéuticos y de laboratorio 41.376.621,87 7,6%
Mat sanitario fungible 18.373.486,69 3,4%
Otros suministros de material 3.270.195,82 0,6%
Otros gastos 1.427.326,23 0,3%
Trabajos otras empresas 25.359.426,80 4,7%
Dietas personal 302.589,01 0,1%
Investments 6.189.361,29 1,1%
Concerts costs 30.399.165,41 5,6%
Prosthesis and stents costs 14.962.901,26 2,7%
Others costs 10.000.000,00 1,8%
Total 544.275.350,73 100,0%

7. Sumary
The introduction
The problem
The solution
Lessons & learnt

8. The problem

9. The problem

10. The problem
Current Health Systems

11. The problem
Current Health Systems

12. Sumary
The introduction
The problem
The solution
Lessons & learnt

13. Policies
Models
Best practices
Scientific evidence

14. Key elements
1. Identify and stratify population
2. Planning and coordinate care within all health care levels, using
case management methodology
3. Specific guidelines and protocols for each disease
4. Specific educational disease programmes
5. Integrated Information Systems
6. Evaluate and improve quality, cost and service
7. Align resources and incentives

15. Key elements
1. Identify and stratify population
2. Planning and coordinate care within all health care levels, using
case management methodology
3. Specific guidelines and protocols for each disease
4. Specific educational disease programmes
5. Integrated Information Systems
6. Evaluate and improve quality, cost and service
7. Align resources and incentives

16. Population stratification
5%
60% CASE MANAGEMENT
15%
DISEASE MANAGEMENT
80%
SELF CARE
40%
HEALTH PROMOTION AND DISEASE PREVENTION

17. Population stratification
Department LA FE: 260.000 population
≥ 3 admissions
2.500 15
CASE MANAGEMENT
13.000 75 ≤ 2 admissions
DISEASE MANAGEMENT
115.500 675 No admissions
SELF CARE
HEALTH PROMOTION AND DISEASE PREVENTION

18. Key elements
1. Identify and stratify population
2. Planning and coordinate care within all health care levels, using
case management methodology
3. Specific guidelines and protocols for each disease
4. Specific educational disease programmes
5. Integrated Information Systems
6. Evaluate and improve quality, cost and service
7. Align resources and incentives

19. The New Model
TRADITIONAL CARE MODEL CHRONIC CARE MODEL
Counsel re: Deal with
• Care is Proactive
Lifestyle Acute Attack
Review
Changes of Disease Reinforce • Care delivered by a health care
Labs team
Access Positive
Social/Other Health
Services Behaviours • Care integrated across time, place
Talk with and conditions
Reassure Family
• Care delivered in group
Complete
Diagnose
Forms
appointments, nurse clinics,
telephone, internet, e-mail, remote
General Consultation Review
Referral 10 minutes Care care technology
Plan
Reviwe/Adjus Review • Self-management support a
t Rx and Tx Routine Modify and/orHistory responsibility and integral part of the
Preventive Negotiate
Care Care Plans delivery system

20. The New Model
Sase Level 3 High complexity
management
60%
Level 2 High risk
Disease
management
self care
Level 1 Low risk
Self care
support/
management
40% Healthy promotion Level 0, Healthy

21. The New Model
Coordinated & Integrated Care
En resumen
Modelo de gestión de enfermedades crónicas del departamento La Fe de la Agencia Valenciana de Salud:
Actividades más importantes
Actor Nivel 3 Nivel 2 Nivel 1 Nivel 0
• Autocuidado
Pacient • Automonitorización  Autocuidado,  Autocuidado,
Primary Care
Paciente / Cuidador • Telemonitorización  Automonitorización.  Automonitorización. Hábitos de vida saludables
Carer • Uso adecuado de los recursos y de la
medicación
 Telemonitorización  Telemonitorización
• Formación e información • Formación e información • Formación e información
Primary
Equipo de Atención
• Atención domiciliaria y ambulatoria
programada y urgente
• Atención domiciliaria y
ambulatoria programada y
• Atención domiciliaria y
ambulatoria programada y
•
•
Formación e información
Atención domiciliaria y
Care
Primaria • Elaboración plan de cuidados con urgente urgente ambulatoria programada y
UHD • Comprobar inclusión en el • Comprobar inclusión en el urgente
• Comprobar inclusión en el programa programa programa
• Formación e información • Formación e información
Case
Gestora de casos
•
•
Seguimiento del paciente
Resolución de dudas del paciente
•
•
Seguimiento de 6 meses
Resolución de dudas
Manager • Coordinación con todos los recursos
asistenciales
• Coordinación recursos
asistenciales
• Formación en domicilio (3 dias) y
Hospital at
Unidad de
Hospitalización •
evaluación inicial del paciente
Elaborar el plan de cuidados con AP
•
•
Medico de enlace
Atención a domicilio en
Secundary Care
Home
Domiciliaria • Medico de enlace crsis de PP
DESCOMPENSACION
• Atencion a domicilio en crisis de PP
• Evaluación del riesgo de PP • Evaluación del riesgo de PP
• Atencion crisis de PP • Atencion crisis de PP
Acute Geriatric
Unidad Médica de
Corta Estancia
• Soporte a especialistas en la
asistencia de PP
• Soporte a especialistas en
la asistencia de PP
• Derivación de pacientes • Derivación de pacientes
• Información y formación al paciente • Seguimiento de la • Información y formación al
Specialist
Servicios • Seguimiento de la evolución del evolución del paciente paciente
Especialidad paciente • Atención en consulta • Atención en consulta
• Atención en consulta programada programada programada
09-30-00044-Departamento La Fe- Modelo de crónicos 02-VF4
–PP – Paciente Pluripatológico Página 96 de 142

22. The New Model
Nurse “Case manager”

23. The New Model
Involve patient and family

24. Key elements
1. Identify and stratify population
2. Planning and coordinate care within all health care levels, using
case management methodology
3. Specific guidelines and protocols for each disease
4. Specific educational disease programmes
5. Integrated Information Systems
6. Evaluate and improve quality, cost and service
7. Align resources and incentives

25. Guidelines and protocols
“Innovando los Cuidados de las Condiciones Crónicas”

26. Guidelines and protocols
Educative interventions
Factors that exacerbate disease
Exacerbation symptoms recognition
Knowledge about disease and treatment
Therapeutic compliance

27. Key elements
1. Identify and stratify population
2. Planning and coordinate care within all health care levels, using
case management methodology
3. Specific guidelines and protocols for each disease
4. Specific educational disease programmes
5. Integrated Information Systems
6. Evaluate and improve quality, cost and service
7. Align resources and incentives

28. Healthcare Integrates
- ERP -

29. The New Model
Telemonitoring Services
Nurse “Case manager”
Involve patient and family

30. Telemonitoring Services (Pilot phase)

31. Key elements
1. Identify and stratify population
2. Planning and coordinate care within all health care levels, using
case management methodology
3. Specific guidelines and protocols for each disease
4. Specific educational disease programmes
5. Integrated Information Systems
6. Evaluate and improve quality, cost and service
7. Align resources and incentives

32. Policies
Models
Best practices
Scientific evidence

33. The Results – “Pilots”
CASE
MANAGEMENT
DISEASE
MANAGEMENT
SELF CARE
HEALTH PROMOTION AND DISEASE PREVENTION

34. The results: CHF Pilot
Comparative analysis
RESOURCES Pre Manag
Average admissions CHF per patient 1,5 0,4 73,3%
Density admissions CHF 4,2 1,0 76,2%
Average stays per patient 11,4 2,6 77,2%
Density stays 43,9 8,6 80,4%

35. The results: CHF Pilot
Comparative analysis
RESOURCES Pre Manag
Average care atention all causes 3,6 1,4 61,1%
Average care atention CHF 1,9 0,4 78,9%
Density incidents urgency (all) 9,8 4,7 52,0%
Density incidents urgency (CHF) 5,3 1,3 75,5%
“Innovando los Cuidados de las Condiciones Crónicas”

36. The results: Palliative Care Pilot
Comparative analysis
RESULTS %
Exitus location at Home 74,2 %
Exitus location in Hospital 25,7 %
Sedation exitus at home 23,0 %
Hospital readmision 2,7 %
Derived to HML 3,4 %
“Innovando los Cuidados de las Condiciones Crónicas”

37. Key elements
1. Identify and stratify population
2. Planning and coordinate care within all health care levels, using
case management methodology
3. Specific guidelines and protocols for each disease
4. Specific educational disease programmes
5. Integrated Information Systems
6. Evaluate and improve quality, cost and service
7. Align resources and incentives

38. Align resources and incentives
Strategic Map - Departament Health LA FE
To guarantee services of health
A that satisfy the necessities and B To guarantee the economic
the expectations with the
sustainability of the system
population
Population and Society Patients Financials
C. To im prove the health results F. Improve the accessibility J. To m axim ize incom e
D. To generate confidence and security G. Lend decisive attendance and to m anage the investments
in the system H. Harness personalization K. To optim ize the costs
E. To respect environment I. Increase to fidelización and attraction L. Im prove the productivity
Promotion of the Suitable use of resources and Clinically Pioneering Development of
health optimized processes appropriate development of the the knowledge
attendance portfolio of services
1 To make the To harness the
promotion of 4 12 To orient
domiciliary attention 11 Potenciar
healthful and the 7 To harness 9 To innovate the investigation
docencia e
habits hospitalization clinical with the
investigación
security attention of
2 alternatives chronic activity in line
5
To present Rational use conditions
the system of diagnose 8 To impel the 10 12 To order
tests
3 Guarantee 6 To adapt use of the to innovate teaching to
the pharmaceutical best practices the portfolio of increase its
prevention prescription services impact
Improve the To align the
availability of the Impel the use To manage
investments 16
13 strategic 14 and security of 15 with the alliances with
intelligence the TIC agents nails
strategy
To develop the human potential
To incorporate
To orient the To implant a To plan the the To impel the
organization to System of 19 RR.HH for the 20 To improve the 21
sharpshooting 22 organizational
17 18 satisfaction of
the strategy Recognitions change professionals knowledge change

39. Align resources and incentives
.........................
MANAGEMENT
AGREEMENT
.........................
DEPARTAMENT LA FE 20%
Departamento de Salud nº 7

40. Align resources and incentives
PRIMARY CARE SECUNDARY CARE
Home
Care
Acute
Stay
Hospitalitation
Emergnecy
Emergency
Amulatory
Care
Ambulatorry Complex
Care

41. Align resources and incentives
SECUNDARY CARE
PRIMARY CARE
Case Managers
Acute Mediium & Long
Case Geriatric Stay
Home management Unit Unit
Care
Hospital
at Hospital Support Team
Home
Disease
Emergnecy management
Acute
Stay
Hospitalitation
Emergency
Ambulatorry Self care Ambulatoriy
Care support/ Care Amulatory
management Specialist Care
Complex

42. Align resources and incentives
Resources “care proactive” 2011
Primary Care Team
Doctor 1 / 1.500
Nurse 1 / 2.000
Hospital Home Unit Team
Doctor 1 / 20.000
Nurse 1 / 10.000
Case Managers * 1 / 125
*Chronic Level 1 High complex

43. Align resources and incentives
Resources “care reactive” 2011
Hospital Support Teams 2
Acute Geriatric Unit 45
Medium Stay Unit 56
Convalescence
Palliatives Care
Long Stay Unit 28
Mental Health Unit 28
“Innovando los Cuidados de las Condiciones Crónicas”

44. Align resources and incentives
e-Chronic Disease Management Service

45. Align resources and incentives
e-CDM Service
5%
60% CASE MANAGEMENT
1.500 € year / user
15%
DISEASE MANAGEMENT
80%
SELF CARE
2.000 Case management
40%
HEALTH PROMOTION AND DISEASE PREVENTION
3.000.000 € year

46. Sumary
The introduction
The problem
The solution
Lessons & learnt

47. Lessons & learnt
20% Technological
and
80% cultural

48. Lessons learnt
E-CDM Service
3
HIS
1
2

49. Align resources and incentives
e-CDM Service
5% 260.000 population
60% CASE MANAGEMENT
1.500 € year / user
15%
DISEASE MANAGEMENT
e-Health & e-Disease
80% 2.000 Case management
SELF CARE
Management
40%
HEALTH PROMOTION AND DISEASE PREVENTION
3.000.000 € year
3.000.000 € year

50. An introduction
Capitation
Concepts Expenses %
Personal costs 371.962.870,10 68,3%
Operating costs 110.761.052,67 20,4%
Arrendamientos 2.618.677,60 0,5%
Reparaciones 6.625.557,57 1,2%
Material oficina e informática 1.619.786,59 0,3%
Consumos energéticos, telefonía y ostales 9.416.549,05 1,7%
Vestuario y lencería 370.835,45 0,1%
↓ 10% Pharmaceutical and laboratory products 41.376.621,87 7,6%
health products and consumables 18.373.486,69 3,4%
Otros suministros de material 3.270.195,82 0,6%
Otros gastos 1.427.326,23 0,3%
Trabajos otras empresas 25.359.426,80 4,7%
Dietas personal 302.589,01 0,1%
Investments 6.189.361,29 1,1%
Concerts costs 30.399.165,41 5,6%
Prosthesis and stents costs 14.962.901,26 2,7%
Others costs 10.000.000,00 1,8%
Total 544.275.350,73 100,0%

51. Lessons & learnt
20% Technological
and
80% cultural

52. Lessons & learnt
Departamento de Salud nº 7

53. Lessons & learnt

54. Lessons & learnt
Departamento de Salud nº 7

55. Lessons & learnt