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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
Tighter Budgets
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 Plan 2016-2020
Population health and lifestyle habits, by gender, 2011 to 2014
Population Health Plan 2016-2020
Population Health Plan 2016-2020
Prevalence of tobacco consumption among the 16-64 people, by
employment status and gender, 2006 and 2013-2014
Population Health Plan 2016-2020
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)
Plans to manage chronic diseases in Catalonia
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)
Plans to manage chronic diseases in Catalonia
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
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(!)
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
COM Salut
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
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
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.
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
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
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
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

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  • 1. 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
  • 2. ImprovingPublic HealthcareQuality inCatalonia Knowledge Generation in healthcare delivery Human resources Hospitals management and Consultancy
  • 3. 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
  • 4. 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
  • 6. Unstoppable Expansion of New Treatments  Biologic therapies start to be prescribed by Primary Care Physicians The Economist, Jan 3rd 2015. Going Large.
  • 7. 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
  • 8. 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/
  • 9. Evolution of life expectancy for people born in Catalonia 1983-2013 Population Health Plan 2016-2020
  • 10. Main chronic disorders among the 15+ age group in Catalonia, 2014 Population Health Plan 2016-2020
  • 11. Population health and lifestyle habits, by gender, 2011 to 2014 Population Health Plan 2016-2020
  • 12. Population Health Plan 2016-2020 Prevalence of tobacco consumption among the 16-64 people, by employment status and gender, 2006 and 2013-2014
  • 13. Population Health Plan 2016-2020 BMI by gender, 18 to 74 age group. Catalonia 2014
  • 14. Population Health Plan 2016-2020: Setting Targets
  • 15. Population Health Plan 2016-2020: Evaluation
  • 16. 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) Plans to manage chronic diseases in Catalonia
  • 17. 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(!)
  • 18. 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) Plans to manage chronic diseases in Catalonia
  • 19. 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.
  • 20. Inductors of model changes Home as the hub for delivery care Co-responsibility of patients and families Reduce insitutionalization
  • 21. 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
  • 22. 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
  • 23. 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
  • 24. • 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
  • 25. • 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. 26 PPAC & PIAISS Strategic Lines 2017-2020
  • 27. 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. 28 The PIIC (Individual Intervention Plan) is a common and updated document, accessible on-line for every health provider, containing...
  • 29. 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
  • 30. Prevalence of patients with a well-filled PIIC Source: Catsalut, 30th September 2016 Objective 2017 Barcelona Health Region: Good PIICs (Individual Intervention Plan)
  • 31. Prevalence among people with good PIIC Source: Catsalut, 31st December 2015 PIICs (Individual Intervention Plans) with good, bad o without completion in Catalonia
  • 32. 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
  • 33. 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(!)
  • 34. 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
  • 35. 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
  • 37. 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).
  • 38. Primary Care – continuous monitoring of outputs & outcomes Adequacy
  • 40. Primary Care Homecare (% of population over 64 years with domiciliary visits)
  • 42. Primary Care Cost of Medication
  • 43. Primary Care “Essential” project: adding value to clinical practice http://observatorisalut.gencat.cat/ca/central_de_resultats/
  • 44. 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
  • 45. Integrated Homecare of chronic complex patients Entrance Point and Unique Provisions:
  • 46. 1. Integrated Homecare of complex chronic patients Tracking Indicators: Information Shared with Social Services:
  • 47. 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
  • 48. 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
  • 49. Making hospitals smaller EESRI 2008. Rechel B. Investing in hospitals of the future. 2009
  • 50. 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
  • 51. 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
  • 52. Reduce the Use of Hospitals Need to Share Costs with community Carers to be more involved Inductors of model changes
  • 53. 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
  • 54. 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
  • 55. 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
  • 56. Post-Acute Care Acute Rehabilitation Days admitted Acute Rehabilitation Days admitted
  • 57. Subacute Units Acute Rehabilitation Acute Subacute Home Rehabilitation Days admitted Days admitted
  • 58. 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
  • 59. 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.
  • 60. 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%
  • 61.         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
  • 62. 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
  • 63. 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
  • 64. 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
  • 65. 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.
  • 66. 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
  • 67. 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
  • 68. 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
  • 69. 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