© 2014 IBM Corporation 1© 2015 IBM Corporation

Mr. Juan Carlos Contel,

Department of Health, Government of Catalonia, Spain

The journey from a Chronic Care Program to an Integrated Health

and Social Care model in Catalonia

Singapore, 28th May 2015

“Integrated Care in Practice”

Session structure• A new and different Health Plan and the

introduction of a new STORY • Chronicity Prevention and Care

Program: the “journey” toward Integrated Care

• Complex Chronic Care as catalyst of Integrated Care

• A new journey toward a new Integrated

health and social care model

• ICT developments to support new Integrated Care model: shared eHR (HC3) and “i-SISS.cat” contribution

• Integrating health and social care information

The Spanish National Healthcare System

• NHS funded by taxes • Decentralized to regional autonomies• Universal coverage• Free access• Very wide range of publicly

covered services• Co-payment in pharmaceutical products• Services provided mainly in public facilities• Interterritorial Board to coordinate policies

Catalan Healthcare System: some basic features

• Area: 32,106 km2• Population: 7,611,711 inhabitants. 17% over 65 y.

(expected 32% in 2050)• 1780 € expenditure per capita and 1150 € public expenditure

per capita in 2012 • Life expectancy: 82.27 years• Gross Mortality rate (2010):8/1,000 inh.• Infant mortality (2010): 2.6 /1,000 live births• 369 Primary Health Centres (PHC) ranging from 20-45,000

inh)• 69 “acute hospitals” (no far from 50 Km. from every home)• 96 “long term care” centres (residential homes: long-stay,

convalescence, pal.liative care)• 41 Mental Health Centres

Public System Network:

• 367 Primary Care Teams • 69 Acute care hospitals (14,072 beds) • 96 Long-term care centers• 41 Mental healthcare centers

Healthcare data

Primary Health Care (PHC):•Almost 1500-2000 inh. per family doctor and community nurse•Salaried + Bonus related Payment by Results (betw. 8-12% salary)•Availability specialty in family Medicine (4y.) and Community Nursing (2y.)•Well implemented PHC evaluation framework for all professionals

Catalan Healthcare System

USER

USER

SERVEICATALÀ

DE LA SALUT100%

SERVEICATALÀ

DE LA SALUT100%

SUPLEMENTARYPRIVATE

INSURERS 20%

SUPLEMENTARYPRIVATE

INSURERS 20%

INSTITUTCATALÀSALUT (public)

77%

INSTITUTCATALÀSALUT (public)

77%

PRIVATECENTERS

10%

PRIVATECENTERS

10%

CONTRACTED NON-PROFIT PROVIDERS

23%

CONTRACTED NON-PROFIT PROVIDERS

23%

Commissioner PHC Provision

Catalan Healthcare System

USER

USER

SERVEICATALÀ

DE LA SALUT100%

SERVEICATALÀ

DE LA SALUT100%

SUPLEMENTARYPRIVATE

INSURERS 20%

SUPLEMENTARYPRIVATE

INSURERS 20%

CONTRACTEDPRIVATE

NON-PROFIT PROVIDERS

75%

CONTRACTEDPRIVATE

NON-PROFIT PROVIDERS

75%

PRIVATECENTERS

10%

PRIVATECENTERS

10%

INSTITUT CATALA SALUT (public)

25%

INSTITUT CATALA SALUT (public)

25%

Commissioner Hospital Provision

Source: IDESCAT, 2015

Ageing in Catalonia 2013-2051

In 2050:1/3 over 65 y.>12% over 80y.

Total population: 7,49 million in 2013 and 7,95 million in2051

Elderly projection:

•> 65 y.: 1,30 million in 2013 and 2,45 million in 2051•> 80 y.: 0,41 million in 2013 and 0,94 million in 2051•Centenarians: 1.700 in 2013 and 21.600 in 2051

Life expectancy at 65 years:

Men: 18,7 in 2012 and 22,6 in 2050 (4-year increment)Women: 22,7 in 2012 and 26,5 in 2050 (4-year increment)

Life expectancy at birth:

Men: 80 in 2015 and 85,33 in 2050 (5-year increment)Women: 85,6 in 2015 and 90,21 in 2050 (5-year increment)

Population projection 2013-2051

Source: IDESCAT, 2015

Hospital admission by diagnostic groups > 70 y.

Source: DGPRS. Dep Salut, 2013

COPD

HF

Urinary Infection

Asthma

Diabetes with complications

Source: Catalan Health Plan 2011-2015.

The Catalan Health Plan 2011-2015

Health Programs: Better health and quality of life for everyone

Health Programs: Better health and quality of life for everyone

Transformation of the care models: better quality, accessibility and safety in health procedures

Transformation of the care models: better quality, accessibility and safety in health procedures

Modernisation of the organisational models: a more solid and sustainable health system

Modernisation of the organisational models: a more solid and sustainable health system

I

II

III

For each line of action, a series of strategic projects will be developed, which make up the 31 strategic projects of the Health Plan.

For each line of action, a series of strategic projects will be developed, which make up the 31 strategic projects of the Health Plan.

9. Improvements to information, transparency and evaluation

1. Objectives and health programs

7. Incorporation of professional and clinical knowledge 6. New model for contracting health care

5. Greater focus on the patients and families

8. Improvement of the government and participation in the system

2. System more oriented towards chronic patients

3. A more responsive system from the first levels

More PHC !!!

4. System with better quality in high-level specialties

Launched at the end 2011

Strategic lines of the Chronic Care Program

All

stra

teg

ic lin

es

req

uir

e

ICT t

ools

an

d d

evelo

pm

en

ts

• Integrated Care Pathways as a formal agreement among

professional clinical leaders at local level

• Based on reference clinical guidelines and

best evidence practice

• Critical key points identification

• Critical variables uploaded at Shared Clinical record

• 80% of territories implemented 3 of 4 chronic conditions:

COPD, depression, heart failure and DM2. Now Complex Cronic Care

Pathways work

• Agreement on different “situations”: 0. Diagnosis, 1. Stable,

2. Acute exacerbation, 3. Management difficulty, 4. Transitional

Care, 5. 24/7 guarantee (!)

Integrated Care Pathways

Healthy33%

Chronic non complex62%

Complex3,5%

Advanced1,5% End of life Bereavement

PREVENTIVE APPROACH

CURATIVE APPROACH

PALLIATIVE APPROACHSELFCARE

COLLABORATIVE CARE

Taking care of complex patients

16

PCCMultimorbidity

Severe unique diseaseAdvanced frailty

MACALimited live prognosis Palliative approach,

Advance care planning

Two profiles of complexity

Stratification must be validated by clinicians determining “complex chronic condition and advanced chronic disease” condition

-Care centres that have patients classified and marked in these two types, can publish this label/mark in HC3- The classification / label must be visible on all the screens , given the importance of the condition- It has been incorporated in July 2013 version to HC3 stratification with Clinical Risk Groups (CRGs)

PCC: Complex Chronic Patient

MACA: Advanced chronic disease

“Shared Individual Intervention Plan” (PIIC)

Health problems/DiagnosisActive MedicationAllergiesRecommendations for “in case

of crisis” or exacerbationAdvanced Care PlanningResources & SOCIAL services usedMultidimensional assessmentCarer whom are delegated

decisionsAdditional information of interest

Initial Health Plan target (!):25,000 complex chronic patients should be identified by 2015In May 2015 over 150,000 patients included1,5% of Catalan population

Evolution in number of PCC and MACA

“Labeling” available since January 2013 !

NEW SHARED INTERVENTION PLAN (PIIC)• Diagnostics• Medication Plan• Allergies• Recommendations in case of CRISIS or acute exacerbations: dyspnea, pain, fever, behavior change

• Advanced Care Planning: preferences, values, therapeutic adequacy

• Multidimensional Assessment: functional, cognitive and social risk

• Social Services utilization: Home care, Home help, telecare, case management

• Emergency admissions and A&E visits in last 12 months

• Living alone ?• Carer information

Basic assessment in Complex Chronic Patients• Basic standardized and customized assessment: Functional +

Cognitive impairment + Social Risk + Depression• NECPAL assessment to identify “Advanced Chronic Disease” condition• Complementary assessment

Challenge: To construct a shared and joint Health and Social Assessment and Intervention Plan

Multimorbidity unified data base

Insured data sourceNIA, demographic data

Diagnosis data baseNIA, tipus_codi, codi, data dx ,UP,

tipus_UP

“Contact” data baseNIA, dates contacte ,UP, tipus_UP,

urgent, CatSalut, T_act.

MDS-Hospital

MDS-PHC

MDS-MH

MDS-Long Term

MDS-A&E

Central RegisteredInsured

Health Problems

Pharmacy (PHC and hospital

provided)

Pharmacy data baseNIA, ATC, data dispensació, unitats,

Import

Mortalitat (INE)

Data sources

MDS-Social Services MDS: Minimum Dataset

Multimorbidity in Catalonia obtained by stratification

Challenge:It is required to include “social data” to adjust stratification

http://146.219.25.61/msiq/index.html

DM2

COPDDEPRE

OSTEOARTHRITIS

Prevalence of multimorbidity

Heart Failure

Information available at regional and PHC level

Stratification and Emergency admission risk

CRG RSCIdentification people at risc Proactive

measures

Classification people at risk

Segmentation for the proactive management of people at risk

Identification and recording at Clinical Record

Returning population stratified data base

Chronic disease selectionHospitalizations 

Risk

ID DM HF COPD Asthma Other: Nº emerg admisssion

Hospital Cumulative days

CRG (status

and severity)

Hospitalization Rate

Mortality Rate

ZAGO234… 1 1 0 0 1 3 18 7.4 80% 40%

ROGU675.. 1 0 1 0 1 1 8 7.3 65% 28%

Selection of patients by different criteriaDifferent pyramids related to different Risk approach:

Future hospitalization / Death / Future cost

1% 18% 133% 10.992€ 13% 13%

2% 7% 57% 5.872€ 13% 26%

8% 3% 28% 3.162€ 28% 54%

17% 1% 14% 1.411€ 25% 79%

72% 0% 2% 282€ 21% 100%

POPULATION MORTALITYRATE

HOSPITAL. RATE

ESTIMATED EXPENSE

% ACCUMU-LATED

Impact distribution of different segments

Visualization in Shared Clinical Record and different RISK scores

Morbidity group and RISK calculated and published twice a year

Description of different RISK segments

CRG information (morbidity group),

severity and Hospitalization Risk

CRG information (morbidity group),

severity and Hospitalization Risk

• CRG 7/5 • 3 emergency

admissions• Hospitalization Risk

of 35%

PCC/MACAPCC/MACA

Included in “CASE MANAGEMENT” Program

Included in “CASE MANAGEMENT” Program

CRG and Risk score visualization

Ad-hoc “queries”:Every professional could perform a basic query combining stratification and current chronic conditions and other variables (pharmacy,…)

It could be selected 1 or more chronic conditions

Stratification segment code

Expected per capita expenditureAverage expenditure (€)

Primary Care Pharmacy Emerg.adm. A&E Outpatient Clinics

AGE

Primary Care

Pharmacy

Emergency admissions

Outpatients clinics

Expected per capita expenditureAverage expenditure (€)

Primary Care Pharm. Emerg.adm. A&E Outpatient Clinics

COPDDiabet. Dement Card. CVAMent. Cirros. KidneyH. Fail. Neopl.VIH

Primary Care

Pharmacy

Emergency admissions

Outpatients clinics

Constructing a new GMA morbidity grouper in Catalonia

Source: CatSalut, 2014

Mortality PHC contacts Hospitalization A&E use

CRG vs GMA CRG vs GMA CRG vs GMA CRG vs GMA

Constructing a new stratification model for Integrated health and social care

To identify people at higher risk to be admitted in a nursing home or to be home social care high intensity user

Proposal of sharing indicators

Indicators Primary Care

Hospital Care

Social Care

Avoidable Hospital Admissions ++ ++ +

Home Care program Coverage ++ - ++

Health outcomes: good control, process and treatment

++ ++

Readmission rate in Chronic Obstructive Pulmonary Disease (COPD) and Heart Failure (HF)

++ +++ +

COPD/HF Avoidable Hospital Admission

++ ++

Discharge planning in “PRE-Discharge” program

++ - -

To ensure continuity care in “POST-Discharge” program

- ++ ++

“Quality of life” (HRQoL) assessment

++ ++ ++Challenge: To aggregate health and social care data

New contract in 2013: Common PHC-Hospital Targets

38

COMMON TRANSVERSAL OBJECTIVES(20%)Reduction Avoidable Hospital Admissions Rate (composite, HF and COPD)Reduction 30-day Readmission Rate for HF and COPD (also composite)Get minimum value prescription pharmaceutical index% minimum discharges with contact before 48 hours after discharge

% minimum register screening risk factors Metabolic syndrome TMS

SPECIFIC TRANSVERSAL OBJECTIVES (“TERRITORY”) (20%)% minimum PCC/MACA with Intervention Plan (“PIIC”)% minimum PCC/MACA with medication review% minimum PCC/MACA with post-discharge medication conciliationReduction emergency admissions in PCC/MACAMinimum number participants Expert Patient Program% minimum COPD patients with spirometry% minimum PHC with Mental Health integrationPrevalence minimum depresion with “severity” criteria% minimum patients with depresion with “suicide risk” assessmentDevelopment at local level a consultant virtual office“Amputation rate” reduction in DM“Ophthalmology/locomotor “ referral first visits under expected tax

Challenge:A new Shared and Joint Integrated Health and Social Care Outcome Framework should be developed

SISAP: Professionals System InformationYou MUST identify an expected prevalence

Comparison with Team and all organization

Screen display of indicators by doctors and nurses. (!) Monthly data updated !!! Differentiated internal weight among indicators

SISAP: Professionals System Information

Comparison with Team, area, region and organization in Catalonia

Screen display of indicators by doctors and nurses. (!) Monthly data updated !!! Differentiated internal weight among indicators

Heart Failure: patients treated with ACE

+2,4% last year variation

Multidimensional assessment in Home Care

+2,6% last year variation

Hospital admissions for chronic conditions

Monthly udpated information!

Includes: COPD, HF, DM complications, asthma, coronary diseases, HTA

Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region / sector / PHC team (x 100.000 inhab. Tax)

Source: MSIQ, Catsalut

−8 %last 36 months

Potentially avoidable hospital admissions for COPD

Decrease by 13,8 % from Dec 2011 to Dec 2013 (36 months)

Availability of evolution of avoidable emergency admissions per region / sector / PHC team (x 100.000 inhab. Tax)

X 100.000 inh.

Potentially avoidable hospital admissions for heart failure

Source: MSIQ, CatSalut

Decrease by 2 % from Dec 2011 to Dec 2014 (36 months)

Availability of evolution of Avoidable Emergency admissions per Region / Sector / PHC Team (x 100.000 inhab. Tax)

New trend!Increase by 26% from 2005 till 2011

X 100.000 inh.

Emergency admission rate in asthma

Decrease 5,8% between Dec. 2011 to Dec. 2014 (36 months)

x 100.000 hab.

Emergency admission rate related to diabetes

Decrease 14,2% between Dec. 2011 and Dec. 2014 (36 months)

x 100.000 hab.

30-day readmission for a range of chronic conditions (composite)

Decrease 8,5% between Dec. 2011 till Dec. 2014 (36 months)

Included: COPD, Heart Failure, DM, asthma, coronary diseases

Decrease readmission between Dec. 2011 till Dec. 2014 (36 months): -6,5% COPD / -10% HF / -4,5% Asthma

30-day readmission for a range of chronic conditions

COPD HF Asthma

Emergency admissions related to Chronic cond. exacerbation

Information available at “county” levelAlmost the half emergency admissions compared to Catalan average

(x 100.000 inhab.)

“La Garrotxa” is an high performing Integrated Heath and SOCIAL Care county

Emergency admissions related to COPD exacerbation

More than the half emergency admissions compared to Catalan average

(x 100.000 inhab.)

“La Garrotxa” is an high performing Integrated Heath and SOCIAL Care model

Emergency admissions related to HF exacerbation

Almost the half emergency admissions compared to Catalan average

(x 100.000 inhab.)

“La Garrotxa” is an high performing Integrated Heath and SOCIAL Care model

Information available at “county” level.More than a half emergency admissions compared to Catalan average(adjusted data)

Emergency admissions related to chronic conditions

La Garrotxa is an high performing Integrated Heath and SOCIAL Care model

Emergency admissions in a “Primary Health Care team”

Almost 25% less emergency admissions for a range of chronic conditionsX 100.000 inhab.Information available for the 369 Primary Care Teams

List of patients sorted by “gaps”

ID PACIENT “GAP”

New “panel management”introduced

56

•It has been converted information into warnings when we access to clinical record in each visit

•Customized configuration per professional and Team

•Warnings sorted by importance and relevance

•Weekly calculation (“online” proposal)

•“Front-office” and “back office” modality

Mean 20-30% improvement in some scores !

WARNINGS and ALERTS

Discharge Planning

Challenge: To incorporate new hospitals beyond ICS and long term care facilities guaranteeing “Transional care” with Primary Health Care and Social Services

Basis for a Social and Health Integrated Care Plan for Catalonia:

PIAISSPIAISS

Integrated Health and Social Care is high priority and policy in England

https://www.gov.uk/government/policies/making-sure-health-and-social-care-services-work-together

Direcció d’Atenció Primària Costa de Ponent

25th February 2014:New Government Agreement where is launched a new Integrated Health and Social Care Plan in Catalonia

Accountable and reporting to Department of Presidency

Care model oriented to:

•To respond to people who have complex health and social needs•It is based on a shared participation in decision making by the person•To promote collaborative practice and co-responsibility between the parties and a shared care plan elaborated by the different professionals belonging to different organizations and areas of care•Triple Aim vision!: To achieve better health and wellbeing outcomes, a more appropriate utilization of services and a better perception of care 

Integrated Care: PIAISS proposal

“Microsystems”•Community-based and primary care leadership •Integrated care pathways•Multiprofessional work•Transitional care •Out of hours care•Home care strategy

Joint case / care load: Shared needs assessment + action plan

Stratification models: assessing population needs

Clinical and professional leadership

Health and social care local governance

Shared outcome framework: shared responsibility & join accountability Aligned incentives:

shared vision about the use of resources

Shared Electronic Health and Social record

Person Centered Care: Empowerment and Self-care

ENABLING ELEMENTS

Multi-lever approach: Multi-lever approach: ALL things at the same timeALL things at the same time

Culture and change management

Catalonian Integrated Care model:Set of elements to support Integrated Care

PIASS strategic lines:Roadmap approved February 2014

Integrated, community-based care, i. e. primary social and health care

Integrated Care “Home care” model

Adaptation of long-term health and social care and mental health

Regulation of care in residential care facilities

Interaction between the health and social care areas of the mental health and drug addiction and HIV/AIDS network

Improvement of the “dependency care” system

Integrated information systems

Collaborative and relational ecosystem

Sustainability and stability

Population-based framework of joint assessment

Integrated care as an innovative practice

Primary Care

Information from Centres/Hospitals

Specialist Care

Diagnostic Procedures

Diagnostics

Prescriptions

Vaccination

Hospital Discharge Report

A&E Report

Specialist Care Report

Lab Results

RX Report

Other diagnostic reports

Hospital Data

Information from Dep of Health

Electronic Prescription

Diagnoses

Procedures

Discharge Data

Prescription

Medication Plan

Shared Clinical Record (HC3) implemented

67

Shared Medical Record – Summary display

Documents published per year

29.270.546

2014 Images > 5 M

Image publication

Chronic patients labeled

24.837 MACA

More than 100 million

clinical records

available

 

2014

113.354 PCC

Shared information systems: constructing a new eClinical and Social care record •CIP (Identification Number) as a common identifier.•Prior agreement on the coding and register of social problems.•Prepare the local social services information system for it to be ‘interoperable’ in a short-medium term and provide a minimum set of information and variables for a Shared Social and Clinical Record •Access to a minimum set of information and variables of common interest on social field for the Shared Clinical Record of Catalonia (HC3). 1st stage: generation of a Social Intervention Plan incorporated to HC3. 2nd stage: Shared Individual Intervention Plan.•Communication systems to improve accessibility, messaging and virtual work between social and health areas.•Introduce social variables gradually to available health stratification.

Challenges to construct and Integrated Health and Social Care record

Health and social Health and social integrated careintegrated care

Size of the project

72

PILOT

Health Department with HC3 (Shared Medical History of Catalonia)

City Council of Barcelona with SIAS (Social Services Information System of Barcelona).

Centres, programs and facilities of health and social care, that are property of the City Council of Barcelona and of the Health Department.

Phase 1 : Basic primary social servicesPhase 2 . Specific social services

WHO IS INVOLVED?WHO IS INVOLVED?

PLANNING PLANNING

Health and social information sharing

73

CategoryHCCC (Shared Medical History of

Catalonia)SIAS (Social Service Information System of

Barcelona)

ID information

Name and surnameID card

Date of birth

AddressTelephones

Age

Name and surnameGender

Date of birthID card or passport

AddressTelephones

E-mailCensus

Services information

Professionals (general practitioner, nurse)

Health centre, palliative care, home care, nursing homes...

Professional (social worker)Social services centre

Supplementary information

Economic information: pharmaceutical copaymentLegal incapacity: process, date, guardian

Health information

Health factors (diagnostic)Chronically ill categorization

Very ill categorization

Disability: recognized level, kind of disability, disable scale.

Dependent people: recognized level.Risk alert (coronary heart disease, fall s...)

Needs assessment

Barthel ADL indexLawton-Brody's index

Pfeiffer cognitive evaluation testZarit Burden Interview

Barthel ADL indexLawton-Brody's index

Pfeiffer cognitive evaluation testZarit Burden Interview

Social risk factors (Health at home - Salut a Casa)

Social diagnosis

Intervention

Individual health intervention planIndividual Treatment

Previous medical discharge (24-48 ours before)

Medical discharge documentsA&E documents

EMS (emergency medical services )documents

Services: Home care services Telecare Food assistance Day care centres

Community care Programs/projects Programs/projects

“PCC / MACA” condition

Shared Individual Intervention Plan (“PIIC”)

Diagnostics/ Health problems

“Dependency degree” formal assessment

“Home Help” services label

“Telecare” services label

Social Care Intervention Plan

Pharmacy prescription

Health Care Health Care Social Care Social Care

+ Social

“Health and Social” Integrated eCarePilot project in pioneer territories

Variables: functional, cognitive deterioration, ….

Variables: functional, cognitive deterioration, ….

Professional viewer HC3

Health professionals can use two methods look up information in the HC3

Integrated into any health information system

Legal framework REGULATIONS

AGREEMENTThe “Framework agreement" has been signed between the Health Department and the City Council of Barcelona concerning the exchange of information among HC3 (Shared Medical History of Catalonia) and Social Service Information System of Barcelona.

CONSENTInformed consent to ask the citizen authorization to share their health and social information.

PERSONAL IDENTIFICATION NUMBERThe “Personal Identification Number” has been established as the common identifier in health and social systems. 76

Law 12/2007, October 11th, of Social Services and professionals who are involved in the monitoring and evaluation of the citizen.

Law 21/2000, September 29th, about the rights of information concerning the health and autonomy of the patient, and clinical documentation.

Law 44/2003, Novembre 21th, to regulate profiles of health professions.

Agreement GOV / 28/2014 of Febraury 25th, to create the Integrated Health and Social Care Plan (PIAISS), in the Government Plan 2013-2016, to promote, lead and participate in the transformation of the social and health care model to achieve a person-centred integrated care model.

SNOMED CT

• Example:

DescriptionIds

ConceptId

Hierarchy relationships

Social Problems codification

A Web Service is a method of communication between two electronic devices over a network. This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona).

Security Common repository

Informed consent will be signed by the citizen. The health or social professional will send the document to the common repository . Each professional can check if the citizen has signed this consent.

Informed consent will be custodied in a common repository. It will be validated by both systems. It will do periodic checks.

Send informationReceive information

Receive information

Send informed consent

and check

Technological terms

Send information

Health Departament Information System

Social Service Information System

i-SISS.Cat

Strategic plan for the implementation and deployment of the platform for the

management of healthcare and social care Processes in Catalonia

80

• Management of the different clinical processes included and priorised in the Healthcare Plan

• To introduce real virtual work substituting face-to-face work• To assure interoperability between different providers, unifying

the model of integration and information sharing• To share data and construct processes with Social Care provision• To measure ”directly” the relevant indicators established within

the Health Plan and Catalan Outcome Framework• To share with the patient and citizen the management of his/her

health in an enhanced self-management approach

The i-SISS.Cat solution should allow:

MAIN CHALLENGES

1.GOVERNANCE2.HOLISTIC POINT OF VIEW.3.INTEGRATED CARE.

GOVERNMENT 360º VISION

INTEGRATED PROCESSES

INTEGRAL VISION

•Creation of programs and tracking key performance indicators (KPIs).•Display of results for program and service provider.

• Access to the broad view of the patient and the process •Environments of collaboration between professionals.

• Shared Social and health-related information •MDT platform

• Platform that will allow us to expand the coverage to other social benefits and giving coverage to the unique social and health record.

The i-SISS.Cat solution challenges:

Integrated Care Complex Care Pathway with Social Services

PHC

Sever.

Referral Appointment Results

PHC

Sec Care

PHC

To plan appointmentTreatment response

Sec. Care

Good

Appointment

Bad

Results

HF confirmation

Appointment

Outpatient

No HF confirmation

Priority

PHC

Yes No

Stable

Yes No

Appointment

Outpatient

Admission

RISK RISK TO DEVELOP COMPLEX HEALTH AND SOCIAL TO DEVELOP COMPLEX HEALTH AND SOCIAL NEEDSNEEDS

COMPLEX HEALTH AND SOCIAL

NEEDS

HIGH HEALTH HIGH HEALTH AND SOCIAL AND SOCIAL COMPLEXITYCOMPLEXITY

CO

MPLEX

SO

CIA

L N

EED

S

CO

MPLEX

SO

CIA

L N

EED

S CO

MPLEX

HEA

LTH

NEED

S

CO

MPLEX

HEA

LTH

NEED

S

1

2

3

45

6 7

Complex health and social needs ?

The need of incorporating Social Services in the definition of a JOINT Care Plan

Continuity of care

Integrated health and social care: shared approach

Multiple front door (mainly at Prim. care). Unique response

Implementation (efectiveness, coordination, multidisciplinarity)

Join and comprehensive assessment for health and social needs

Shared proactive action Plan

Monitoring, evaluation and feedback

person-

centred

Empowered citizens

- selfcare

Shared

information

Professional

leadership

Identification and registering (in the community)

Community based care

Case m

an

ag

em

en

t / S

hare

d c

are

Comprehensive

approach

Shared vision

& shared outcome

Shared needs assessment instrument

2 alternative options to be decided:

1.To adapt a validated commercial solution: interRAI, SMAF,…

1.To construct a shared need assessment instrument based on professional consensus

*It is required to facilitate collaborative environment between professionals working in different areas of health and social services

Multi-lever approach: Multi-lever approach: ALL things at the same timeALL things at the same time

Catalan Integrated Care model: some lessons

• Strong Government commitment is required to overcome current barriers, especially legal issues

• ICT interdepartamental governance is required: Department Health and Welfare aligned

• Social care sector could understand and feel benefits to use collaboratively health sector experience to accelerate change and transformation

• Joint and intense working between Integrated Health and Social care Plan and ICT departmental Unit

• Joint both health and social care commissioning teams should be committed to joint commissioning

• To introduce incentives to encourage providers introduces innovations and improvements

• Clinical and professional leaders should be involved in co-producing “person-centered care” solutions