![12/05/2015 6
Pilot Goals’ Summary
• To rely on Primary Care to better track chronic patients needs avoiding
unnecessary usage of Acute resources [decentralized care model]
• Social Workers from Quart de Poblet are added to our Heart Failure
Multidisciplinary Group to better track what social care actions can
complement the clinical pathway
• INCA used to load HF Care Plan protocols into INCA IT Tool
• Results of HF Care Plan implementation are compared against indicators
we had before INCA
• Cost-Effectiveness (doing more) + Cost-Utility (raising quality)
Dr. Rafael Sotoca MD MPH Manises Health Department
INCLUSIVE INTRODUCTION OF INTEGRATED CARE => IN3CA. INCA (www.in3ca.eu).
INCA: MANISES PILOT](https://image.slidesharecdn.com/sotocamaniseshospitalpilot-150721085130-lva1-app6891/75/Manises-Success-Case-AdsuM-eHealth-Week-2015-6-2048.jpg)
Uploaded byAlejandro Echeverria
Manises Success Case - AdsuM+ (eHealth Week 2015)
The document outlines the integrated care pilot program led by Dr. Rafael Sotoca at the Manises Health Department in Valencia, Spain, focusing on chronic disease management and the coordination of health services. It aims to enhance primary care tracking for chronic patients while integrating social workers for improved support. The initiative seeks to increase cost-effectiveness and quality of care through the implementation of specific health protocols and monitoring systems.
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Manises Success Case - AdsuM+ (eHealth Week 2015)
- 1. MANISES HOSPITAL PILOT Dr.Rafael Sotoca MD MPH Manises Health Dept. Valencia. Spain.
- 2. Spain Cyprus LatviaCroatia Spain Manises/Quart Geroskipou Ventspils Rijeka Cartagena 500 150 200 200 500 > 65 Heart Failure Cerebrovascular Accidents Arterial Hypertension Mental Health Problems Diabetes Type 2 / Heart Failure 12/05/2015 2 INCLUSIVE INTRODUCTION OF INTEGRATED CARE => IN3CA. INCA (www.in3ca.eu). Dr. Rafael Sotoca MD MPH Manises Health Department INCA PILOTS
- 3. INCA: MANISES PILOT Dr.Rafael Sotoca MD MPH Manises Health Department12/05/2015 3 • Who we are: Manises Health Department; public health area managed under a Public- Private-Partnership (PPP) model. • What we do: deliver primary, specialized and acute health services to 200,000 people in 14 municipalities • 10 Primary Care Centres + 10 Auxiliary Centres + 9 24/7 Primary Centres + 2 Specialty Centres • 1 Reference Hospital + 1 Chronic Hospital (long term and palliative) INCLUSIVE INTRODUCTION OF INTEGRATED CARE => IN3CA. INCA (www.in3ca.eu).
- 4. 12/05/2015 4Dr. RafaelSotoca MD MPH Manises Health Department Population N3 N2 N1 N0 Promotion,prevention, and MeetingthedemandPlanned,cross-cutting, integratedhealthcare High complexity chronic patients Moderate complexity chronic patients Low complexity chronic patients Healthy population, or acute processes Focus on the person Focus on the disease Focus on Risk Factors and Disease Progression Focus on promoting healthy habits and decisive social factors PROMOTION OF SELF-CARE AND PERSONAL AUTONOMY, CARER HELP AND SUPPORT, DEPARTMENTAL INVOLVEMENT Cancer screening HBP Obesity Smoking Dislipemia Diabetes Sedentary lifestyle Arthrosis & om degenerative Inappropriate diet Depression & Anxiety Alcohol abuse Heart Failure COPD Acute Coronary Syndrome Stroke Neuro- degenerative disorders Major mental disorders Palliative care Asthma HEALTHY HABITS PRIMARY HEALTH CONDITIONS INCLUSIVE INTRODUCTION OF INTEGRATED CARE => IN3CA. INCA (www.in3ca.eu). INCA: MANISES PILOT MAJOR STABLISHED DISEASES
- 5. 12/05/2015 5 - NYHALevel - Last Admission Social Resources at Local Level INCLUSIVE INTRODUCTION OF INTEGRATED CARE => IN3CA. INCA (www.in3ca.eu). INCA: MANISES PILOT Heart Failure Dr. Rafael Sotoca MD MPH Manises Health Department
- 6. 12/05/2015 6 Pilot Goals’Summary • To rely on Primary Care to better track chronic patients needs avoiding unnecessary usage of Acute resources [decentralized care model] • Social Workers from Quart de Poblet are added to our Heart Failure Multidisciplinary Group to better track what social care actions can complement the clinical pathway • INCA used to load HF Care Plan protocols into INCA IT Tool • Results of HF Care Plan implementation are compared against indicators we had before INCA • Cost-Effectiveness (doing more) + Cost-Utility (raising quality) Dr. Rafael Sotoca MD MPH Manises Health Department INCLUSIVE INTRODUCTION OF INTEGRATED CARE => IN3CA. INCA (www.in3ca.eu). INCA: MANISES PILOT
- 7. 12/05/2015 7 MDG andcare coordination INCLUSIVE INTRODUCTION OF INTEGRATED CARE => IN3CA. INCA (www.in3ca.eu). INCA: MANISES PILOT Dr. Rafael Sotoca MD MPH Manises Health Department
- 8. 12/05/2015 8Dr. RafaelSotoca MD MPH Manises Health Department INCA: MANISES PILOT INCLUSIVE INTRODUCTION OF INTEGRATED CARE => IN3CA. INCA (www.in3ca.eu).
- 9. 12/05/2015 9Dr. RafaelSotoca MD MPH Manises Health Department INCA: MANISES PILOT INCLUSIVE INTRODUCTION OF INTEGRATED CARE => IN3CA. INCA (www.in3ca.eu).
- 10. THANK YOU Dr. RafaelSotoca MD MPH rsotoca@hospitalmanises.es David Dapena. CIO SANITAS ddapena@hospitalmanises.es 12/05/2015 10Dr. Rafael Sotoca MD MPH Manises Health Department