From care in clinically complex cases to a model of integrated health and social care: The Alt Penedès Experience M. Domènech M.J. García L. Martinez J.C. Molina P. Piñeiro ACT General Assembly, Barcelona. June 17, 2015
From care in clinically complex cases to a model of integrated health and social care: The Alt Penedès Experience M. Domènech M.J. García L. Martinez J.C.
Dec 23, 2015
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From care in clinically complex cases to a model of
integrated health and social care: The Alt Penedès Experience
M. DomènechM.J. GarcíaL. MartinezJ.C. Molina
P. PiñeiroACT General Assembly, Barcelona. June 17, 2015
A long long time ago...
From care in clinically complex cases to a model of integrated health and social care Alt Penedès2/32
Geographic situation: Spain > Catalonia > Alt Penedès
From care in clinically complex cases to a model of integrated health and social care Alt Penedès3/32
Barcelona
CATALONIA
Alt Penedès
Barcelona
Region: ALT PENEDÈS
Outside of the covered area
Vilafranca del Penedès Basic Healthcare Area (ABS)
Sant Sadurní Basic Healthcare Area (ABS)Penedès Rural Basic Healthcare Area (ABS)
From care in clinically complex cases to a model of integrated health and social care Alt Penedès4/32
Vilafranca
96,287 inhabitants562 km²
26 towns45 % rural19.5 % > 65 years old9.9% > 75 years oldAgeing index: 99
De l’atenció a la complexitat clínica a un model d’atenció integrada social i sanitària Alt Penedès5 /32
CAP Monjos
Primary Healthcare Centre(CAP)
Ricard FortunyHealth and Social Care Centre
Vilafranca City Council Social Services
Monjos Primary Healthcare Centre(CAP)
Primary Healthcare Centre(CAP)
Region: ALT PENEDÈS - Healthcare centres
35 service points Primary Care (Health and social)
Progress 2010-2014
2010 2011 2012 2013 2014
― 149 238 331 1.438
YEARPopulation
attended
InnovationPlan
CCP+
CHF
CCP+
CHF+
COPD
CCP+
CHF+
COPD+
Design: collaborative
model+
Design: Nursing Home Care Team (EAR) Project
CCP+
CHF+
COPD+
Other pathologies+
Implementation: EAR
+First agreements:
collaborative model
From care in clinically complex cases to a model of integrated health and social care Alt Penedès6/32
Beginning of the Program...
2010
―
InnovationPlan
• CatSalut (Catalan Commissioning Health Authority): demands for Primary and Hospital Care to develop pilot chronic care projects.
• Profile of COMPLEXITY-FRAGILITY-MULTIMORBIDITY-SOCIAL RISK.
• Leadership: Multidisciplinary working group comprised of representatives from
each area of healthcare and facilities involved in CCP care. Professionals with clinical recognition in any of the environments. Commitment to leadership and participation, promoting adherence
to other professionals. Collaboration of the health authority: The project will be more likely
to succeed if professionals feel supported
From care in clinically complex cases to a model of integrated health and social care Alt Penedès7/32
Patient Profile
2010
―
InnovationPlan
From care in clinically complex cases to a model of integrated health and social care Alt Penedès8/32
Chronic complex patient (CCP): Healthcare requirements
• High level of Use of Hospitalization services and social and health resources. Polypharmacy: risk of side effects and interactions.
• A dynamic situation that requires follow-up and monitoring over time; the intensity of care should be adjusted to each situation.
• Care for these patients: requires more than one professional all opinions should be shared and incorporated into the decision-making process.
• Proactive care is beneficial to control and prevent flare-ups and imbalances.
Target population - How to identify the patient
2010
―
InnovationPlan
• Top stratus from Kaiser´s pyramid), using a Prediction model.
• Data from ECAP (the Clinical Work Station for Primary Care) and the minimum basic data set (CMBD).
• Congestive heart failure (CHF) is prioritized: high hospital admission rate
From care in clinically complex cases to a model of integrated health and social care Alt Penedès9/32
2011
Population: 149
CCP+
CHF
• Organize care provided by professionals according to a flexible, integrated, proactive care model.
• Change the provision of services, using a model of shared care with circuits improving communication
• Share information: three clinical record systems. Use of the shared clinical history
• Involve patients and their families in self-care.
• Train professionals involved in the project.
• Assess the development of the program: indicators can be used to detect aspects to improve.
Operational objectives of the project
From care in clinically complex cases to a model of integrated health and social care Alt Penedès10/32
2011
Population: 149
CCP+
CHF
Existing resources
Social and health care - Vilafranca Healthcare Consortium (CSSV)ConvalescenceLong stay
Hospital care - Alt Penedès Healthcare Consortium (CSAP)UFISSUCIESLiaison nursePREALTHospitalization UPCA
Primary care- Catalan Health Institute (ICS)Primary care teams Case management nurses: 3 Liaison nurses: 1PADESACUT
UGC
From care in clinically complex cases to a model of integrated health and social care Alt Penedès11/32
2011
Population: 149
CCP+
CHF
• Clinical stability• Hard to control• Flare-ups• Hospital admission• End-of-life care
From care in clinically complex cases to a model of integrated health and social care Alt Penedès12/32
Design and implementation (1/3) - Situations and circuits
2011
Population: 149
CCP+
CHF
Design and implementation (2/3) - First assessment - 4 months
• First estimates of the results were inconclusive, but...
We needed to Extend the awareness and Identification of patients to professionals, because in practice:
• Models of patient stratification and risk prediction are useful and complementary at the beginning, providing lists of target patients
• A chronic patient is complex when the professional responsible for him/her considers this to be the case. CCP are identified using the, professionals' clinical criteria.
From care in clinically complex cases to a model of integrated health and social care Alt Penedès13/32
2011
Population: 149
CCP+
CHF
Design and implementation (3/3) - Detection. How to improve it
Prediction model Primary healthcare team (EAP): doctor
or nurseSocial and health care
Death Transfer
outside of the region
Patient refusal
Regional hospital (UPCA, PREALT, CE)Case Management
Unit
Basic Social Services (SSB, 2013) Nursing Home Care Team
(EAR, 2013)
From care in clinically complex cases to a model of integrated health and social care Alt Penedès14/32
CCPP (1/11) - Progress during 2012
2012
Population: 238
CCP+
CHF+
COPD
• Drawing up treatment Integrated Care pathways in the region, redirected towards CCP.
• Incorporation of COPD and use of CHF facilities and circuits.• Informal contact with social services directors in the region.• Assessment at 16 months.• Economic assessment.
From care in clinically complex cases to a model of integrated health and social care Alt Penedès15/32
Chronic Complex Patient Programme
CCPP (2/11) - Assessment: main results
2012
Population: 238
CCP+
CHF+
COPD
• Reduction in consumption of hospital resources.• Increase in primary care activity, specially management
nurses.• No effect on the patient's state of health, with
progressive deterioration: Natural history of CCP. High average age
• Key points: Case management nurses. Acute Chronic Patient Unit (UPCA), with proactive
out-patient care.• Remaining Patients with high use of resources: low
social support.
From care in clinically complex cases to a model of integrated health and social care Alt Penedès16/32
2012
Population: 238
CCP+
CHF+
COPD
CCPP (3/11) - Economic assessment
From care in clinically complex cases to a model of integrated health and social care Alt Penedès17/32
• The cost-effectiveness assessment was carried out from the perspective of the health system.
• Data from the first 16 months were used (149 patients).
CCP+
CHF+
COPD
2013
Population: 331
CCP+
CHF+
COPD+
Design ofa collaborative
model+
Design of the Nursing Home Care
Team (EAR) project
CCPP (4/11) - 2013: the year of change
Globally, Catalonia:
• HC3 Identification of CCP and Advanced chronic disease
• Creation of an individual and shared intervention plan (PIIC).
• Start of the design of a collaborative model project to integrate social and health services:
In case of Alt Penedès county, with CCPP.
From care in clinically complex cases to a model of integrated health and social care Alt Penedès18/32
2013
Population: 331
CCP+
CHF+
COPD+
Design ofa collaborative
model+
Design of the Nursing Home Care
Team (EAR) project
CCPP (5/11) - 2013: the year of change
Locally, Alt Penedès:
• Creation of the Chronic Care Unit (Primary Care): Case Management Unit (nurses and social workers). Advanced Chronic Disease Support. Design of the Nursing home care project.
• Agreements 7x24.• Review of the pharmacological plan.• Start circuits to incorporate the others CCP, not COPD or CHF.• Training and more training of professionals.• Interconnection of the three IT systems.• Assessment at 28 months.
From care in clinically complex cases to a model of integrated health and social care Alt Penedès19/32
2013
Population: 331
CCP+
CHF+
COPD+
Design ofa collaborative
model+
Design of the Nursing Home Care
Team (EAR) project
From care in clinically complex cases to a model of integrated health and social care Alt Penedès20/32
CCPP (6/11) - Nursing Home Care TeamTEAM AND PROJECT• Objective: provide the same care in nursing homes as at home.
• Direct care: Reference team (emergency and scheduled care).
• 9 centres included in the program(768 places),
• Around 80% have a CCP profile.
• Coordination with professionals from nursing homes and EAP.
• Social assessment and review: Adaptation of provisions, and allocation of resources. Work with the family, patient and the centre to draw up the
PDA (advance decisions plan).
CCPP (7/11) - 2013: evolution of resources
2013
Population: 331
CCP+
CHF+
COPD+
Design ofa collaborative
model+
Design of the Nursing Home Care
Team (EAR) project
Hospital Care - Alt Penedès Healthcare Consortium (CSAP)UPCA
Primary care - Catalan Health Institute (ICS)Chronic Care UnitCase management (nurses and social workers)EARAdvanced Chronic Disease Support
Social and health care - Vilafranca Healthcare Consortium (CSSV) PADESPalliative care unit
Social services Basic Area of Social Services, Alt Penedès Regional Council (CCAP)Basic Area of Social Services, Vilafranca
Other providers:• 061• Tertiary Services • Mental health centres, children and
adolescent mental health centre, care and attention service team, etc.
From care in clinically complex cases to a model of integrated health and social care Alt Penedès21/32
2013
Population: 331
CCP+
CHF+
COPD+
Design of a collaborative
model+
Design of the Nursing Home Care
Team (EAR) project
From care in clinically complex cases to a model of integrated health and social care Alt Penedès22/32
Summary of circuits
Complex chronic patientClinical stabilityHard to controlFlare-upAdmissionEnd-of-life care
Primary CareGeneral Practice - Community nursing Case managementACUTAdvanced chronic disease supportEAR
SSB Vilafranca and Sant SadurníSEVADDependency and social SADCommunity food servicesBAT...
Hospital CareInternal medicine consultancyUPCAHospitalisationEmergency DepartmentUFISS
CSSVIn-patient services: convalescence - long stayDay hospitalDay centre PADESUDAP
Mental Health
CIMCA061 - Medical Emergency ServiceHealth Transport
CCPP (8/11) - Design and implementation
CCPP (9/11) - Identification of patients
2013
Population: 331
CCP+
CHF+
COPD+
Design ofa collaborative
model+
Design of the Nursing Home Care
Team (EAR) project
From care in clinically complex cases to a model of integrated health and social care Alt Penedès23/32
in the HC3 and in X-Clínic Portal
CCPP (10/11) - Assessment at 28 months
2013
Population: 331
CCP+
CHF+
COPD+
Design of a collaborative
model+
Design of the Nursing Home Care
Team (EAR) project
Results on the consumption of hospital resources:
Patients and characteristics• Average age: 81.2 years (SD: 7.75).• Comorbidity CRG 6 and CRG 7: 90.8%.• Charlson Index: 27.4% patients. Charlson > 4. • Social risk: differentiating criteria for frequent users.
From care in clinically complex cases to a model of integrated health and social care Alt Penedès24/32
CCPP (11/11) - Assessment at 28 months
2013
Population: 331
CCP+
CHF+
COPD+
Design ofa collaborative
model+
Design of the Nursing Home Care
Team (EAR) project
Descriptive resultsPrimary care activity• Case management nurses visit 99% of these patients (86%
home visits).• Increase in home visits in primary care by GPs and nurses.Social and health care center activity• 19% of the patients have been admitted once or more.• Referrals Hospital care 51% and primary care 34%.UPCA decision (day hospital)• 89% of patients return home.Pharmacy• The average initial number of drugs was 12.34 (SD 3.9) vs.
11.74 (SD 4.22) at the end (p: 0.027).
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Collaborative model with Social Services (1/2)
Lines of work/strategies
2014
CCP+
CHF+
COPD+
Other pathologies+
Implementation of EAR
+First agreements
collaborative model
From care in clinically complex cases to a model of integrated health and social care Alt Penedès26/32
HEALTHCARE CONTINUITY
• Integrated circuits for internal proceduresinvolving all resources (one window).
• Leaders at each level. Maintain the case managementunit as a reference in primary care.
• Improve the Hospital discharge planning, offering: • Social home care service(SAD). • Home Assistance Program (ATDOM).• Communicate high risk through UGC.
Population: 1.438
2014
CCP+
CHF+
COPD+
Other pathologies+
Implementation of EAR
+First agreements:
collaborative model
Collaborative model (2/2)
Lines of work/strategies
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PRIORITIZATION Integrated SEVAD (dependency assessment service): priority
assessment agreement. Community leader of SEVAD. Establish shared assessment criteria to prioritization resources. Joint evaluations to set the individual and shared intervention
plan.
OTHERS• Shared information:
HCCC proposal to make all required information accessible from all care areas.
Coding of reasons for a consultation.• Shared training: last quarter of 2014.• Relational environment: trust, respect and knowledge.
Population: 1.438
Conclusion The establishment of partnerships between the health and social services
will enable:• Adaptation of the resources to the situation and the person's needs.• Improvement in the efficiency of resource use.• Prolongation of the time remaining at home, with the same quality of life.• We agree with ‘what’, now we must agree on ‘how’.
but... SAFELY
From care in clinically complex cases to a model of integrated health and social care Alt Penedès28/32
PersonSocial
Services, Vilafranca
City Council
CCAP Other organi-zations
CSSV
HCAP
EAP
EARAdvanced
Chronic Disease Support
UGC
From care in clinically complex cases to a model of integrated health and social care Alt Penedès29/32
EAP
HCAP
CSSV
CCAP
Social Services,
Vilafranca City Council
EAR Advanced Chronic
Care Support
UGC
Other organi-zations
PERSON
From care in clinically complex cases to a model of integrated health and social care Alt Penedès30/32
From care in clinically complex cases to a model of integrated health and social care Alt Penedès31/32
From care in clinically complex cases to a model of integrated health and social care Alt Penedès32/32
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