Post on 31-Mar-2015
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Some issues raised by the implementation of integrated care for patients with chronic diseases
National Implementation of Innovations in Integrated Care Wednesday April 2nd 2014
Dominique POLTONNational Health Insurance, France
1. Organisational models
Some issues raised by the implementation of integrated care for patients with chronic diseases
Patient-centered, high quality care, coordination of interventions from a wide range of professionals, promotion of active patient engagement
2. Tools
4. Efficiency / financial sustainability
Objective
3. Step-by-step approach
National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014
Organisational models (1/5)
Who is the best care coordinator in different situations ?
National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014
GP
Role of other PCPs (nurse / pharmacist)
Multidisciplinary teams
External support & coordination
Case managers / facilitators
Local networksPublic agenciesInsurance funds
Organisational models (2/5)
Who is the best care coordinator in different situations ?
National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014
Role of other PCPs (nurse / pharmacist)
Multidisciplinary teams
External support & coordination
Case managers / facilitators
Local networksPublic agenciesInsurance funds
PRADO (orthopaedic surgery, chronic heart failure)
GP
Organisational models (3/5)
Self management support / patient empowerment
National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014
Role of other PCPs (nurse / pharmacist)
Multidisciplinary teams
External support & coordination
Case managers / facilitators
Local networksPublic agenciesInsurance funds
PatientPatientPatientPatient
Call Call centercenterCall Call
centercenter
Outbound phone calls to medium & high risk patients
Feed backto GP
relays relays relays relays
GPGPGPGP
Internet portal
Peer support (patients groups organised by the French diabetes
association
GP
Organisational models (4/5)
Adaptation to the evolution of professional practices
National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014
Multidisciplinary team in the same premises (medical homes, health care centres) --> therapeutic education, prevention programs,…
GPs and other health care professionals form a team with a project but not in the same premises
New coordinated services without practice redesign --> protocols to ensure homogeneity (i.e. return home program for heart failure patients)
Level 1
Level 3
Level 2
Organisational models (5/5)
But even with multidisciplinary teams different levels of coordination may be needed for some populations, especially to link the cure and care sectors
National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014
PAERPApilot programs in 9 French regions to improve coordination of care for individuals aged 75 and over with complex needs and at risk in
terms of loss of autonomy
Tools
National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014
Shared information among professionals, but also information on the available resources, information for patients
Personalised care plans – e.g. PAERPA Design Compensation (GP + nurse +/- pharmacists)
Training of health professionals
News professions in charge of the coordination for complex cases (which profile ? different situations)
Step-by-step approach
National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014
Electronic multi-disciplinary patient record
First step = development of electronic medical records in GP practice
Exchange of information & Multidisciplinary patient record
Issue = information sharing between health professionals and social workers
From a disease-oriented approach to a global approach
The disease-oriented approach is considered too narrowly focused and not taking into account multimorbidity,
Yet it may be a pragmatic first step to design a pathway
Efficiency/ financial sustainability
National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014
Stratification of patients and adaptation of the level of resources
Example 1 : PAERPA pilots --> care plans for 20% of the population aged 75 and over --> criteria
Example 2 : Case managers : level of workforce needed ?
Example 3 : Therapeutic education programs --> priorities / level of resources devoted
Use of the ICT
Internet portals
Peer support through forums,
Telemedicine…
Questionnaire d’aide à la décision d’initier une démarche de type PPS
chez des patients de plus de 75 ans La personne : O N ?
a-t-elle été hospitalisée en urgence (au moins une fois depuis 6 mois) ?
a-t-elle une polypathologie (n ≥3) ou une insuffisance d’organe
sévère1, ou une polymédication (n ≥ 10) ?
a-t-elle une restriction de ses déplacements, dont un antécédent de chute grave ?
a-t-elle des troubles cognitifs, thymiques, comportementaux (dont addictions) ne lui permettant pas de gérer son parcours, ou mettant en difficulté l’aidant / l’entourage ?
a-t-elle des problèmes socio-économiques (isolement, habitat, faibles ressources) ?
a-t-elle des problèmes d’accès aux soins ou d’organisation des soins ?
Si vous avez répondu OUI à une de ces questions
O N La personne vous paraît-elle nécessiter l’élaboration d’un PPS 1
(suivi pluriprofessionnel impliquant le médecin traitant et au moins 2 autres professionnels) ?
Si oui, accepte-t-elle l’initiation d’un PPS ?