Slide 1 #INTEGRATED CARE@HOME AMADORA´S EXPERIENCE Adriano Fernandes Projects Manager&Consultant
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#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: [email protected]
Adriano Fernandes
Mobile : +351 96 254 94 90