02-e health-european-congress donostia june-2016 ... · PDF file7/2/2016 · Slide 26 •Monitoring/Supervision on going •Communication & Feedbacks •Services...

Slide 1

#INTEGRATED CARE@HOME

AMADORA´S EXPERIENCE

Adriano Fernandes

Projects Manager&Consultant

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0. AMADORA: Challenging Territory

1. MISERICORDIA OF AMADORAa) Culture&Servicesb) Impactc) Managementd) Social&Healthcare Services

2. BEYOND SILOSa) European Frameworkb) Purpose&Goals

3. Amadora´s Approach@Homea) Scopeb) Service Process Modelc) Training on Heathcare&ICTd) Monitoring Tools&ICT Devicese) Gains of Scale&Quality

4. Change Management&Sustainability

a) Change Managementb) Sustainabilityc) SWOTd) Lessons Learnt

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0. AMADORA_CHALLENGING TERRITORY

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• Lisbon suburb• 23,8 km²• 175.558 inhabitants

• 16.000 unemployed people• 30.000 with low education skills• 19% aged over 65• 42% aged over 75• 15% of young people• 35.000 immigrants, 20% of the

universe

CRITICAL INDICATORES

#HEALTH

Diabetes_inbetween 20-79 (7,2%)

Hypertension(19,8%)

Death byCervical

cancer(20,4)-nationalrate=3,4

Tuberculosis(49,1)

Death byisquemiccardiac

disease(15,6)-nationalrate=10,7

Death byStroke(17,7)

-nationalrate=11

AMADORA_An Overview

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1. MISERICORDIA OF AMADORA

#30 Years Serving Well the Community

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MISERICÓRDIA DA AMADORA

• To provide, create and develop appropriate social services in the community of Amadora, promoting solidarity, quality of life and human dignity.

• Respect for human dignity, Social accountability, Ethics, Humanization and Quality of the Servicesprovided, Sustainability, Innovation

• Health(CLIMA / U.C.C./ UAC), C&Y( 4 Children DayCare Centers ,3 Kinder Garden, 1 School, 19 ECCenters), V People (MIT; Social Enterprise, CLDS, Social Store), Elderly (2 NH, 2 DCC, 2 HCS)

• 5300 Clients daily

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TARGET/CLIENTS: EVOLUTION

0 1000 2000 3000 4000 5000 6000

2005

2006

2007

2008

2011

2012/2014

Clients ratio per year

Clients

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IMPACT IN AMADORA COUNCIL

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ORGANISATION CHART

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SOCIAL&HEALTH CARE SERVICES

S&H CareServices

Social

Social&EconomicalDisavantadged

Individuals/Families

Minimum Income; Local Contract for

Social Development

Elderly

2 Nursing Homes;

Services

2 Nursing Homes; 2 Day Care

Centers; 2 HomeCare Support

Services

Health

First Line CLIMA

Second LineLong Term CareUnit, Residential

Houses

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2. Taking integrated care one step further...

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Enable the quality of Life and sense of

security and confort to elderly people

living@Home

Delivering of integrated care to elderly

people to support them to live

independently within the community

-Quality of Life - Self Care

- Integration of Services - Cross Sectorial Teams

- ICT Tools - Evaluation

13 Partners

8 Countries

7 PilotSites

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3.AMADORA´S APPROACH@HOME

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BEYOND SILOS_SCOPE

150 SCMA Clients

20 Equipments

&

Devices

127 Informal Carers

2 CollaborativePlatforms(Training+ Online

Portal)

46

Formal Carers

Slide 15Pathway

Personalised multi-provider service package

Temporary

admission to

institution

(e.g. respite

care)

Monitoring /

review /

reassessment

of care

recipient’s

needs

Exit point:

Disenrollment

from

BeyondSilos

service (ICP-

LTCare)

Entry point

(1):

Referral by

SCMA/Commu

nnity

Assessment

of care

recipient’s

needs for long

term home

care

Enrolment to

BeyondSilos

service (ICP-

LTCare)

Initial

integrated

care plan

Coordination

of integrated

care delivery

/ revision of

initial

integrated

care planOn-site /

home

provision of

formal social

care

Remote

provision of

health &

social care

(telehealth,

telecare)

Shared

documentatio

n of home

care provided

On-site /

home

provision of

formal health

care

On-site /

home

provision of

informal care

Entering into service Receiving continuous personalised care Leaving service

Majpr

exacerbation

/

deterioration

in functional

status leading

to hospital

admission

Exacerbation

/

deterioration

in functional

status

managed at

home

Pathway:

Integrated

Home Support

after Hospital

Discharge

INTEGRATED LT HOME CARE SUPPORT

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BEYOND SILOS_Technological Adaptation

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Mod.1- Welcome&Initial Expectations

Mod.2- Role&Statute of the Carer

Mod.3- Communication

Mod.4-ADL Satisfaction@Home

Mod.5- ADL Satisfaction@Personal

Mód.6- Biomedical Approach

Mod.7- Telemonitoring&Portal

Mód.8- Tele-Assistance

TRAINING: Formal&Informal Carers

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INFORMED CONSENT

DATABASE

PREPARATORY PHASE:

Database&Informed Consent

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Online Platform

Equipments

Devices

TECHNOLOGY ON THE FIELD

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Amadora Num. patients enrolled in BeyondSilos

Enrolled for evaluation Intervention group -

new care

Enrolled for evaluation

Control group -usual care

Foreseen in TA 150 150 150

Current 150 150 150

Amadora Number Detail user typeEg, GP etc

Healthcare providers

10 � 4 GP´s

� 2 Nurses (1 Chief-Nurse)

� 2 Psychologists

� 2 Physiotherapists

Social care providers41 � 5 Social Workers

� 36 Family Assistants

Informal carers; volunteer

support

� 115 Relatives

� 12 Volunteers

ENROLLMENT STATUS

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DIMENSIONS BEFORE BS AFTER BS

SERVICES PROVIDED Social Care(Higyene&Food+Meds)Social&Health Care&Health (Monitoring of Vital Signs+Intervention )

HR INVOLVEDFormal Carers (Social Workers+ FamilySupporters) and Informal (Relatives&Volunteers)

Formal Carers(Social Workers+Nurses+Physioterapists) and Informal Carers

SERVICES SPECIFICATIONS Meals+Cleaning+Meds+Tele-Assistance…+ Telemonitoring (weight,blood pressure, temperature, blood sugar)+ Contact Center

ICT&TRAINING Tele-AssistanceTele-Assistance+Telemonitoring+ Training (b-Learning)

PROCESSES MANAGEMENT @Clients Home @Clients Home+Remotely

INFORMATION MANAGEMENT

Home made DatabasesReports on PapperInexistence of structured planning of Home Care Visits

Structured&Electronic Data BasesElectronic&On Time ReportsStructured&Electronic Home Care visitsscheduling

GAINS OF SCALE&QUALITY

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4.CHANGE MANAGEMENT&SUSTAINABILITY

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ServicesLinking

Communication

Real Time storageand spreading

FasterDecisions

• Vital SignsMonitoring

• Stress&Anxietyreduction

• On site&RemoteMonitoring

• Security&Comfortenhancement

• More Time for what reallymatters…

End Users &Carers Organisations

CHANGE MANAGEMENT

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• Open mind /new mind-set for new Services on Integrated Care

• Change Management internalization

• Wide pool of Stakeholders

• Nourish Care

• Badalona Serveis Assistencials

• University of Twente

• Portuguese Ministry of Health

• In progress @ Amadora with Amadora Municipality; Ministry of Health and Portugal Telecom

• Opportunity of Network of Smart Cities

• EIP-AHA Commited Region

• Gains of Scale for End-users in terms of the quality of the Services provided

• Boosting of SCMA culture and cooperation in between BS Team

• Boosting of synergies within Departments of SCMA

• Gains of Scale in terms of knowledge and Tools/Devices regarding Formal/Informal Carers

EMBEDING&SUSTAINABILITY

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• Internal organisationalchanges in PT Telecom

• Socio-economical crisis

• Stakeholders involved• Model transference

leveraged on new services delivering

• Lack of previousexperiences in thisspecific field

• Adaptation of endusers to ICT solutions

• Activities/Tasksoverloading of Social & Health careprofessional

• Intersectorial consortium• Expertise in social/health

and ICT areas• Integrated intervention on

services delivery• Territorial & target group

characteristics

STRENGTHS WEAKNESSES

THREATSOPPORTUNITIES

6. BEYOND SILOS_SWOT

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• Monitoring/Supervision on going

• Communication & Feedbacks

• Services Linking

• Faster Decisions

• Dematerialisation of Information

t• Added value in terms of the Quality of

Services provided

• Integration of Departments within the Organisation

• Collaborative work in between Partners

• Gains of scale in terms of time saved and tasks

• Importance of trust, mutual support and tolerance

• Complementarity and non duplication of work

• Integration of Services

• Services boosting/New upcoming Services

LESSONS LEARNT

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ESKERRIK ASKO!

MUITO OBRIGADO!

THANK YOU SO MUCH!

Email: adrianofernandes@misericordia-amadora.pt

Adriano Fernandes

Mobile : +351 96 254 94 90