This document summarizes strategies for adopting new chronic patient services at the Hospital Clinic of Barcelona. It discusses: 1. Implementing patient summary records and electronic prescriptions to improve interoperability among providers in Barcelona and across Spain/Europe. 2. Deploying an integrated care model at Barcelona Esquerra involving hospitals, primary care, social services, and mental health to better coordinate care for chronic respiratory patients through structures like an integrated health sector and chronic care unit. 3. Developing integrated care strategies for chronic patients using enhanced lifestyle programs, standardized care paths, and remote monitoring to modulate disease progression and efficiently manage patients in a network of community providers.

1. Estrategias para la adopción de nuevas
prestaciones de servicios para pacientes
crónicos
La experiencia del Hospital Clínico de Barcelona
Josep Roca
Hospital Clinic.IDIBAPS.University of Barcelona

2. Health system redesign

3. INTEROPERABILITY AMONG PROVIDERS
• Level A - Barcelona – Esquerra
• Level B - Spain and Europe
Patient summary record and electronic prescription
BARCELONA ESQUERRA • 540.000 habitantes
EAPs ICS
EAPsCAPSE • 18 ABS y 2 CAPs II (5 empresas
EAP Gesclínic distintas)
EAP LesHortes 5D
EAPsVallplasa
HospitalClínic
• 4 Hospitales
5E
HospitalSagratCor 4C
Clínica Plató
4B
5C 5B • 1 Centro Sociosanitario principal y
5A
4A
CAP II Manso (ICS)
3E 3G 2C 2E otros de menor dimensión
CAP IINumància(ICS) 2B 2D
3D
2A
3B • 3 Proveedores de Salud Mental
3A
3C
• Servicio de Emergencias Médicas de
Cataluña

4. Deployment at Barcelona Esquerra 2009:
Territorial Health Care Comission
Barcelona Esquerra
Institutions Permanent Comission
representative
Technical
Implementation Management
Redesign & follow-up Team
Process 1 Specialized Care
Mental health
Pediatric care
Health Transport
Pharmacy
Home Care
Emergencies
Process 2
Social Care
IT
Process 3
Process 4
Operational Committees

5. Deployment at Barcelona Esquerra 2009:
Hospitals vs territorial healthcare
Community
HOSPITAL Care
Family
Process Units
Transplant Physician
Nurse
Dementia
Social
COPD
Territorial Worker
Healthcare
Home
CHF Care

6. Deployment at Barcelona Esquerra
The Vision

7. STRUCTURES RELEVANT TO CONTINUITY OF CARE
IN CHRONIC RESPIRATORY PATIENTS
INTEGRATED HEALTH SECTOR BARCELONA-ESQUERRA (AISBE)
CHRONIC CARE UNIT
LINKCARE HEALTH SERVICES S.L.
CLINICAL INSTITUTES

8. Integrated Care Strategies for
Chronic Patients
- enhanced citizens life style
- well standardized care paths
Modulation of disease progress
Efficient patient management

9. Service model
• Target patients
• Management by programs
• Well standardized interventions
• Patient-centered care
providers network
Support
Patient
center
Personal Health Folder
• Triage
• Self-management
• Remote monitoring

10. INTERVENTIONS
HOME HOSPITALIZATION
PREVENTION OF HOSPITALIZATIONS
HOME MONITORING
HOME REHABILITATION
HIGH QUALITY SPIROMETRY IN PRIMARY CARE

11. Activity organized by care programs including clusters of
diseases
Cardiovascular
Respiratory
Diabetes - Obesity
Fragile patients

12. Deployment and Adoption
2010-2012

13. Current Deployment at
Barcelona Esquerra (Nexes)
Wellness & Rehabilitation
Frailty - Transitional care - Palliative care
Home hospitalisation
Support

14. Need for operational definitions of frailty
and identification of associated services
System-related factors Patient-related factors Scenario
Organizational model Socio-demographic Integrated care strategies
with ICT support
Professional & health care Chronic conditions
resources
Treatment & self management
Health & Social resources
Dependency
Quality of life
Satisfaction & self-efficacy
information

15. Assignment level of complexity (frailty)
VERY LOW LOW COMPLEXITY HIGH COMPLEXITY
COMPLEXITY in addition, they show some of the
following factors
Patients with 1. More than two co-morbid conditions and Charlson 1. High hospitalization rate in the
none of these index > 2 previous year (> 2 admissions
factors 2. High score of anxiety/depression (HAD > 6) including emergency room visits)
3. Home bound being alone at home for more than 2. Tertiary level therapy at home (non-
50% of the day invasive mechanical ventilation,
4. Home bound with a caregiver of similar age etc…)
5. Treatment adherence assessed by Morinsky- 3. End-stage complex disease
Greens (> 4 different pills/day)
6. Oxygen therapy
7. Need of social support
8. Need of low complexity home care services
(wound cures)

16. Emergency room Hospital specialized units Day care / Home hospitalization
Eligibility assessment of all patients (+ 40 years old) admitted because of
exacerbation of COPD + other respiratory diseases
Not eligible (EXCLUSION CRITERIA)
Accepted to participate
Inability to use the ICT Eligible (INCLUSION CRITERIA)
Living in the area
equipment (patient and
Informed consent
caregiver)
Yes No
Advanced cancer
Patient assessment .
Assignment level of complexity (frailty group)
Number of participants who do
Very low Low High not accept to participate and
their reasons are recorded
Baseline measurements
Randomization
CURRENT CARE
Training/Installation
INTERVENTION CURRENT CARE AT THE
PARTICIPATING HOSPITAL
Very low
Low
High
Follow-up measurements

17. Tailored intervention by level of complexity (frailty)
COMPLEXIT
VERY LOW
LOW COMPLEXITY
HIGH COMPLEXITY
1. Education of self-management including co-morbidities
(pharmacological/non-pharmacological therapies) and
elaboration of personalized action plan
2. Access to the call centre
3. Access to personal health folder
4. Visit at home within 72 h including primary care team and social
support team
5. Video-conference during 1 week
6. Remote sensors monitoring (defined on individual basis by the
specialists)
7. Remote questionnaire monitoring
8. Home-based rehabilitation (physiotherapists and/or occupational
therapists)
9. Connection with convalescence centre (if needed)
10. Video-conference up to 1 month (defined on individual basis by the
specialists)
11. Additional remote sensors (defined on individual basis by the
specialists)
12. Remote support of the specialists including home or day hospital visit
when needed

18. ROADMAP
We should develop the potential to be at the forefront of healthcare delivery innovation
by embracing the evolution of medicine and technology
The 4 P’s of Medicine: System
Predictive Medicine
Personalized
Preventive
Participatory 2020
Personal Health
Services
Evolved Integrated
Care Services 2011
Use of technology