Chronic care in Spain 1 Joan Escarrabill MD Chronic 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
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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
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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
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20012001
2001
Catalonia
1981
Source: Catalan Ministry of Health
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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”
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
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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
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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.
12
34
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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
Therapeutic educationDecision support & uncertaintyPatient’s experience
Transitions “in hosp”Discharge planningStart new therapies
NEJM 2013;368:201-3
Shared policies
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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:
37
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.