Date post: | 04-Jul-2015 |
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Estrategias para la adopción de nuevas prestaciones de servicios para pacientes
crónicos
La experiencia del Hospital Clínico de Barcelona
Josep RocaHospital Clinic.IDIBAPS.University of Barcelona
Health system redesign
INTEROPERABILITY AMONG PROVIDERS
• Level A - Barcelona – Esquerra
• Level B - Spain and Europe
Patient summary record and electronic prescription
EAPs ICS
EAPsCAPSE
EAPs ICS
EAPsCAPSE
EAPs ICS
EAPsCAPSE
• 540.000 habitantes
• 18 ABS y 2 CAPs II (5 empresas
distintas)
BARCELONA ESQUERRA
EAP Gesclínic
EAP Les Hortes
EAPsVallplasa
Hospital Clínic
Hospital SagratCor
Clínica Plató
CAP II Manso (ICS)
CAP II Numància(ICS)
EAP Gesclínic
EAP Les Hortes
EAPsVallplasa
Hospital Clínic
Hospital SagratCor
Clínica Plató
CAP II Manso (ICS)
CAP II Numància(ICS)
EAP Gesclínic
EAP Les Hortes
EAPsVallplasa
Hospital Clínic
Hospital SagratCor
Clínica Plató
CAP II Manso (ICS)
CAP II Numància(ICS)3D
3G
3A
2A
2C
4A
2D
2E
4B5C4C
3E
5D
3C
3B
2B
5A5B
5E
3D
3G
3A
2A
2C
4A
2D
2E
4B5C4C
3E
5D
3C
3B
2B
5A5B
5E
distintas)
• 4 Hospitales
• 1 Centro Sociosanitario principal y
otros de menor dimensión
• 3 Proveedores de Salud Mental
• Servicio de Emergencias Médicas de
Cataluña
Permanent Comission
TechnicalManagement
TeamRedesignImplementation
& follow-up
Barcelona Esquerra
Deployment at Barcelona Esquerra 2009:
Territorial Health Care Comission Barcelona Esquerra
Institutionsrepresentative
Process 1
Process 2
Process 3
Process 4
Em
erge
ncie
s
Soc
ial C
are
Hea
lth T
rans
port
Hom
e C
are
Ped
iatr
ic c
are
Pha
rmac
y
Men
tal h
ealth
IT
Operational Committees
Spe
cial
ized
Car
e
Pro
cess
Un
its
HOSPITALCommunity
Care
FamilyPhysicianTransplant
Deployment at Barcelona Esquerra 2009:
Hospitals vs territorial healthcare
Pro
cess
Un
its
Nurse
Social Worker
HomeCare
Dementia
COPD
CHF
TerritorialHealthcare
Deployment at Barcelona Esquerra
The Vision
INTEGRATED HEALTH SECTOR BARCELONA-ESQUERRA (AISBE)
CHRONIC CARE UNIT
STRUCTURES RELEVANT TO CONTINUITY OF CAREIN CHRONIC RESPIRATORY PATIENTS
CHRONIC CARE UNIT
LINKCARE HEALTH SERVICES S.L.
CLINICAL INSTITUTES
- enhanced citizens life style - well standardized care paths
Integrated Care Strategies for Chronic Patients
Modulation of disease progress
Efficient patient management
pro
vid
ers
net
wo
rk
Service model
• Target patients • Management by programs• Well standardized interventions• Patient-centered care
Patient Supportcenter
pro
vid
ers
net
wo
rk
• Triage• Self-management• Remote monitoring
Personal Health Folder
INTERVENTIONS
� HOME HOSPITALIZATION
� PREVENTION OF HOSPITALIZATIONS
� HOME MONITORING
� HOME REHABILITATION
� HIGH QUALITY SPIROMETRY IN PRIMARY CARE
� HOME MONITORING
Cardiovascular
Respiratory
Diabetes - Obesity
Activity organized by care programs including clusters of diseases
Diabetes - Obesity
Fragile patients
Deployment and Adoption 2010-20122010-2012
Current Deployment atBarcelona Esquerra (Nexes)
Wellness & RehabilitationWellness & Rehabilitation
Frailty - Transitional care - Palliative care
Home hospitalisation
Support
Frailty - Transitional care - Palliative care
Home hospitalisation
Support
Need for operational definitions of frailtyand identification of associated services
System-related factors
Organizational model
Professional & health care resources
Patient-related factors
Socio-demographic
Chronic conditions
Treatment & self management
Integrated care strategieswith ICT support
Scenario
Treatment & self management
Health & Social resources
Dependency
Satisfaction & self-efficacyinformation
Quality of life
VERY LOW COMPLEXITY
LOW COMPLEXITY HIGH COMPLEXITY in addition, they show some of the following factors
Patients with none of these factors
1. More than two co-morbid conditions and Charlson index > 2
2. High score of anxiety/depression (HAD > 6)3. Home bound being alone at home for more than
50% of the day4. Home bound with a caregiver of similar age
1. High hospitalization rate in the previous year (> 2 admissions including emergency room visits)
2. Tertiary level therapy at home (non-invasive mechanical ventilation, etc…)
Assignment level of complexity (frailty)
4. Home bound with a caregiver of similar age5. Treatment adherence assessed by Morinsky-
Greens (> 4 different pills/day)6. Oxygen therapy7. Need of social support8. Need of low complexity home care services
(wound cures)
etc…) 3. End-stage complex disease
Hospital specialized units
Not eligible (EXCLUSION CRITERIA)
NoYes
Patient assessment .Assignment level of complexity (frailty group)
Informed consent
Eligibility assessment of all patients (+ 40 years old) admitted because of
exacerbation of COPD + other respiratory diseases
Number of participants who do
Emergency room Day care / Home hospitalization
Eligible (INCLUSION CRITERIA)
Accepted to participateLiving in the areaInability to use the ICT
equipment (patient and caregiver)Advanced cancer
Randomization
INTERVENTION CURRENT CARE AT THE
PARTICIPATING HOSPITAL
CURRENT CARE
not accept to participate and
their reasons are recordedVery low Low High
Baseline measurements
Training/Installation
Very low
Low
High
Follow-up measurements
Tailored intervention by level of complexity (frailty)
1. Education of self-management including co-morbidities (pharmacological/non-pharmacological therapies) and elaboration of personalized action plan
2. Access to the call centre3. Access to personal health folder
VE
RY
LO
W
CO
MP
LE
XIT
LO
W C
OM
PL
EX
ITY
HIG
H C
OM
PL
EX
ITY
4. Visit at home within 72 h including primary care team and social support team
5. Video-conference during 1 week6. Remote sensors monitoring (defined on individual basis by the 6. Remote sensors monitoring (defined on individual basis by the
specialists)7. Remote questionnaire monitoring8. 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
ROADMAPROADMAP
The 4 P’s of Medicine:
Predictive
Personalized
Preventive
Participatory
Personal Health
SystemMedicine
2020
We should develop the potential to be at the forefront of healthcare delivery innovation
by embracing the evolution of medicine and technology
Use of technology
Evolved Integrated Care Services
Personal Health Services
2011