Chronic care in Spain

1

Joan Escarrabill MDChronic Care Program– Barcelona Esquerra. Hospital Clínic (Barcelona)

Master Plan for Respiratory Diseases (PDMAR) & Home Respiratory Therapies Observatory (ObsTRD). FORES. Ministry of Health (Catalonia)London, July 3th 2013

Agenda

2

CountryRegionArea

Three different perspectives of chronic care1

Controversial issues2

Conclusions3

Spain: Socio-demographic characteristics

(1) Municipal Registre 01/01/2009 INE / INS National Instite of Statistis

(2-6) Eurostat (UE 27=100)

17 Autonomous Communities

Area 504,750 km²

Population (2011)1 47,213,000

Life expectancy (2011)2 82,035 years

Birth rate (2011)3 10.15/1000

Gross Mortality rate (2011)4 8.25/1000

Infant mortality (2011)5 3.0 / 1000 Live Births

GDP Per capita6 $29,289

Source: Catalan Ministry of Health

Health Care in Spain

4

Work Injury Act1900

Social Security Model1945

National Health Service1986

GENERAL HEALTHCARE ACT: 1986 • Universal coverage / Free access• Funded by taxes• Decentralized to regional autonomies• Very wide range of publicly covered services• Co-payment in pharmaceutical products• Strategic direction through “Interterritorial

board”

Source: Catalan Ministry of Health

Health System Decentralization

Central Government

• Basic legislation and coordination. • Financing. • Minimum package funded through NHS.• Pharmaceutical policy.• International health policy.• Educational requirements

Autonomous Government

• Subsidiary legislation. • Public health. • System’s organizational structure.• Accreditation and planning.• Purchasing and service provision

Source: Catalan Ministry of Health

Law without budget

Care delivery responsibilities

without law

Devolution process to AA CC

1984

1987

1987

19901990

1994

2001

2001

2001

20012001

2001

2001

20012001

2001

Catalonia

1981

Source: Catalan Ministry of Health

7

Chronic care

CountryRegionArea

Int J Healthcare Management 2012;5:208-215

Predicitve modeling for population health management Integrated home care Case management Hospital at home Expert patient and “Schools of patients”

Strategies

8

Disease

Groups of diseases

Chronic care

9

20122009

COPD

Strategy Chronic care

Strategy

From To

Chest PhysiciansGeneral PractitionersInternal MedicineNursesPatients

General PractitionersInt Medicine & GeriatriciansNursesPatientsWithout any specialist

No direct relationship with budget or health service delivery

Palliative (2007)Icuts (2008)Cancer (2009)Coronary heart disease (2009)Diabetes (2012)

Ambulatory care sensitive conditions

10

COPD Admissions

www.atlasvpm.org/

11

Chronic care

CountryRegionArea

Master Plans for specific groups of diseases

2000

2010

Valcronic2012

12

www.opimec.org/

http://kronikgune.org/

http://www20.gencat.cat/portal/site/canalsalut

Catalan Health System Observatory

13

Health Policy 2013;111:1–13

Thirty-one telehealthcare initiatives acrosseight countries involving over 20,000 patients

Heterogenity Citizen’s ICT skills Professional’s reluctance Fave-to-face vs tele-health

• Small pilot studies (< 100 pts except WSD)• The challange of interoperability• Problems in the deployment.• No clear consensus on how to measure the

impact• General perception that evidence was lacking

Tele-Health

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<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<

<<<<<<<<<<

Galicia

Basc Country

Catalonia

An example: Catalonia

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CataloniaArea 32.106 km² Population (2011) 7,570,908 (16% of Spain)GDP €170.450 milions (18.8% of Spain)

Health Services: Primary Care

77.6

3.319.1

Catalan Health InstituteMedical GroupsOther providers

367 Primary Care Teams

Public Hospitals(% beds)

70%

30%

Non-profitFormer Social Security

16

H Sta Creu i St Pau. BARCELONA1401

H Sta Creu. VIC.1348

H Sta Maria. LLEIDA1519

Hospitals from “Social Secutiry Model”

1942

7 hospitals

Religious OrdersH S J de Deu1867

Friendly societies1900

56 hospitals

Experiences in Catalonia

HospiceHome support

teams

Geriatrics Palliative Respiratory

Chronic respiratory failure

Escarrabill et alLancet 1985;ii:779

ATDOM

Home carePrimary care

Palliative care

X. Gómez-Batiste et alJ Pain Symptom Manage. 2012;43:783-94

Hernández et al ERJ 2003; 21: 58–67

Hospital at home

Casas et al ERJ 2006;28:123-30

Integrated care Chronic Heart Failure

Rev Esp Cardiol. 2011;64(4):277–285

Escarrabill. The Lancet 1985:ii:779

Long-term oxygen therapy

Legislation changes1990

1988 1991 1993 2000 20120

20406080

100

5.514

34.1

74 73

Sources of oxygen (%)

Cylinder ConcentratorLiquid O2 Portable concentrator

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Int J Clin Pract, March 2012;66;289–298

Health Plan 2011 – 2015:Priorities and Projects9 priority areas and 31 projects

Objectives and Health Programmes

Chronic

Care Orientation

Performance

improvement at primary care

level

Improvement of quality at

high specialization

level

Focus to patients and their families and carers New purchasing and commissioning of health services Clinical and professional knowledge at the front line Governance improvement and professional and citizen’s participation Strengthening the information system, transparency and evaluation

3

2

1

Health Plan 2011 – 2015:Priorities and Projects9 priority areas and 31 projects

Objectives and Health Programmes

Chronic

Care Orientation

Performance

improvement at primary care

level

Improvement of quality at

high specialization

level

Focus to patients and their families and carers New purchasing and commissioning of health services Clinical and professional knowledge at the front line Governance improvement and professional and citizen’s participation Strengthening the information system, transparency and evaluation

3

2

1

Chronic care program

22

Incentives through the funding system

Specific approach to complexity

Clinical Pathways

Stratitification

• Complex patients• End-of-life

• COPD• CF• Diabetes• Depression

Improve integrated care

Increasing the capacity of

resolution of Primary Care

Results

Telehealth in Catalonia

23 Personal Health Folder

Electronical Medical Record

E-Health

Shared Medical Record

> 90% in Primary Care

Tele-ictus program

Electronic prescription• 95% of primary care contacts• > 25% in specialists care

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How to improve care after COPD acute exacerbation?

Some thoughts from a regional perspective

25

The funding system is a necessary lever,

but not sufficient

The challenge is the large metropolitan areas and

the transformation of big teaching hospitals

The changes should affect the entire system, not just hospitals

It is imperative to focus on results, not process.

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Chronic care

CountryRegionArea How a teaching hospital faces the problem of chronic care?

2002-2012

10 of the 50 most cited Spanish documents are from the HC

Blur the boundaries between the HC

and Primary Care

Improve communication

through ICT

The process is always developed

from clinical criteria

Population

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534.955 inhabitants21% > 65 years

19 Primary Care Teams4 hospitals

Barcelona Esquerra

Current situation regarding chronic care

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Diabetes

DebutAge + HbA1cInsulinization

Post discharge

CF

COPD

Integrated care

Frail

LTOT evaluation

Cognitive disorders HIV …

IndicatorsDrug prescription: Joint FormularyICT

3 share policies between Hospital & Primary Care

Current programs at Hospital Clínic

Shared policies

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2003 2012

Policies

Education, information & decision

support

Geriatric care

Transitional care

Confusional syndromePolimedicationMultimorbidities

Therapeutic educationDecision support & uncertaintyPatient’s experience

Transitions “in hosp”Discharge planningStart new therapies

NEJM 2013;368:201-3

Shared policies

30

2003 2012

Policies

Education, information & decision

support

Geriatric care

Transitional care

25% admissions > 75 years

Bray-Hall ST. Ann Intern Med. 2012;157:448-9

Agenda

31

CountryRegionArea

Three different perspectives of chronic care1

Controversial issues2

Conclusions3

Stratification focused interventions in more serious ill.

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BMJ 2012;345:e6017

Where we should make the maximum effort?

More severe patients ???

Stop the progression of the disease ???

The chaos of multimorbidity

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BMJ 2012;345:e5915 doi: 10.1136/bmj.e5915

Continuity & Information

Organization > Evidences ?

Fraily

Complexity

Multmorbidity

Comorbidity

…but organ failure “exists”

The mirage of ICT

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Convergence of all six of the major tecnological advances

The hospital is guilty…

3535

Increased resolution capability of primary

care.

Reduction of hospital admissions of patients with chronic diseases.

Close beds

BMJ 2013;346:f3186

…but Primary Care must also change.

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Primary care is first-contact, continuous, comprehensive, and coordinated care provided to populations undifferentiated by gender, disease, or organ system.

Accessibility = possible use 24/7/365 Finding answers to new problems Always located in a territory and can learn about available resources around

them. Use over time regardless of the type of problem Broad service portfolio (without great additional costs) Recognition of the needs when they occur (alarm) Ensuring continuity Recognize problems requiring follow-up

Reading these features, my daughter said:

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Dad, this is a definition of

smartphone, right?

Accessibility = possible use 24/7/365 Finding answers to new problems Always located in a territory and can learn about available

resources around them. Use over time regardless of the type of problem Broad service portfolio (without great additional costs) Recognition of the needs when they occur (alarm) Ensuring continuity Recognize problems requiring follow-up

Agenda

38

CountryRegionArea

Three different perspectives of chronic care1

Controversial issues2

Conclusions3

Chronic care = “wicked problem”

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2007

• Solutions to wicked problems are not right or wrong.

• Every wicked problem can be considered to be a symptom of another problem.

• Every solution to a wicked problem is a 'one shot operation.'

• Wicked problems have no stopping rule.• There is no template to follow when

tackling a wicked problem.

This demands interdisciplinary collaboration, and most importantly, perseverance.

www.wickedproblems.com/

The role of the "specialist" radically changes

Conclusions regading “Chronic care in Spain”

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There is no specific model for chronic care in Spain.

Still, there were no significant changes in the organization of the health system.

Multiple pilot studies with good results but with little impact on the overall system.

There is no systematic use of ICT.

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2

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SimpleAuthomatic

Good enough

Thank you very much !

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ESCARRABILL@clinic.ub.es