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 ?