juan carles contel, department of health, chronic care program, catalonia

The journey from a Chronic

Care Program towards a

model of Integrate health and

social care

Session structure

• A new Health Plan and the introduction of a new STORY

• Chronicity Prevention and Care

Program: the “journey” toward Integrated Care

• Towards a new evaluation framework:

The first results • A new journey toward a new Integrated

health and social care model

• Promoting self-care of the patient and citizen: Catalonian Expert Patient Program. Towards new Virtual care model

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 health-social centres (residential homes: long-stay,

convalescence, pal.liative care)

• 41 Mental Health Centres

http://www.castellersdevilafranca.cat/images/fotos%20notes%20de%20premsa/vilafranca_timessquare.jpg

Catalan Healthcare System

U S E R

SERVEI CATALÀ

DE LA SALUT 100%

SUPLEMENTARY PRIVATE

INSURERS 20%

INSTITUT CATALÀ

DE LA SALUT 20%

PRIVATE CENTERS

10%

P S N CONTRACTED

PROVIDERS 70%

Insurance Services

Source: Catalan Health Plan 2011-2015.

The Catalan Health Plan 2011-2015

Health Programs: Better health and quality of life for everyone

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

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.

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

4. System with better quality in high-level specialties

2.1 Integrated clinical processes

2.2 Protection, promotion and prevention

2.3 Co-responsibility and self-care

2.4 Alternatives in an integrated system

2.5 Complex chronic patients

2.6 Rational prescription and use of drugs

Strategic lines of the program

7

An increasing number of elderly

5,2% 5,5% 5,7% 6,1% 6,5% 7,2%

8,2% 9,7%

11,2%

13,8%

17,0% 17,2%

19,6%

24,1%

29,2%

31,9%

0,6% 0,7% 0,7% 0,7% 0,9% 1,0% 1,2% 1,5% 1,9% 3,0%

3,9% 5,1%

5,9% 7,2%

9,4%

11,8%

0,0%

5,0%

10,0%

15,0%

20,0%

25,0%

30,0%

35,0%

1900 1910 1920 1930 1940 1950 1960 1970 1981 1991 2001 2011 2021 2031 2041 2049

> 65a > 80a

Source: INE, projections 2011

1/3 of population will be over 65 and 12% will be over 80

Chronic Care Program essential conceptual aspects

• Oriented to people and their needs

• “Population” approach: designed and made for all

• Promotes healthy lifestyles

• People participate from joint responsibility and self-care

• Caregiver and family as main agents in the process of caring

• Social and health approach with a vision of integrated care

• Promotes sustainability and equity of the health system

• “Territorial “ (population based) vision with required Integrated

Care

Healthy 33%

Chronic non complex

62% Complex

3,5%

Advanced 1,5% End of life Bereavement

PREVENTIVE APPROACH

CURATIVE APPROACH

PALLIATIVE APPROACH SELFCARE

COLLABORATIVE CARE

The continuum of chronicity

Healthy 33%

Chronic non complex

62% Complex 3,5%

Advanced 1,5% Terminal Bereavement

PREVENTIVE APPROACH

CURATIVE APPROACH


COLLABORATIVE CARE

Integrated Clinical and Care Pathways

• Integrated Care Pathways as a formal agreement among

professional clinical leaders at local level

• Based on reference clinical guidelines

• How to implement 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

• Other 6 conditions to be included in the future

11

Integrated Care Pathways

Healthy 33%

Chronic non complex

62% Complex

3,5%

Advanced 1,5% End of life Bereavement

PREVENTIVE APPROACH

CURATIVE APPROACH


COLLABORATIVE CARE

Taking care of complex patients

Taking care of complex patients

▪ Stratification model /predictive model

▪ Model of care for patients with complexity

▪ Palliative care-oriented model in persons with advanced chronic disease

▪ Collaborative model between health services and social services: integrated health and social care

14

Multimorbidity unified data base

Insured data source NIA, demographic data

Diagnosis data base

NIA, tipus_codi, codi, data dx ,UP, tipus_UP

“Contact” data base

NIA, dates contacte ,UP, tipus_UP, urgent, CatSalut, T_act.

MDS-Hospital

MDS-PHC

MDS-MH

MDS-NH

MDS-A&E

Central Registered Insured

Health Problems

Pharmacy (PHC and hospital

provided)

Pharmacy data base

NIA, ATC, data dispensació, unitats, Import

Mortalitat (INE)

Data sources

Divisió d’Anàlisi de la Demanda i de l’Activitat

Multimorbidity in Catalonia

Prevalence of comorbidity

17

PCC Multimorbidity

Severe unique disease Advanced frailty

MACA Limited live prognosis Palliative approach,

Advance care planning

Two profiles of complexity

-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

NUCLEAR CARE MODEL

IMPLEMENTATION SUPPORTING GUIDE

Source: PPAC 2013. Departament de Salut

NEW INDIVIDUAL

ACTIONS

TEAM REDESIGN

TERRITORY COMPLEXITY

CARE PATHWAY

Basic requirements

Optimal provision

Excellence

9980

1765

11745

18632

3613

22245

32100

5400

37500

64117

12300

76440

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

PCC MACA TOTAL

15 April 31 May 31 July 31-des

Initial Health Plan target(!): 25.000 complex chronic patients should be identified by 2015 At March 2014 over 80.000 patients included

Evolution of PCC / MACA with a collaborative intervention plan in shared IT

“Labeling” available since January 2013 !

“Shared Individual Intervention Plan” (PIIC)

Health problems/Diagnosis Active Medication Allergies Reccommendations for “in cases

of crisis” or exacerbation Advanced Care Planning Resources and services used Multidimensional assessment Carer whom are delegated decisions Additional information of interest

Check list for support of deployment complexity care model

Basic and Priority: “PCC” and “MACA” identification and labelling + Integrated Care Pathway + 24 / 7 model + Carer identification and support

Level 2 Chronic patients at risk

Case Management

Disease Management

Self-care suport

Level 1 People with stable chronic diseases at early stage

Level 3 Complex chronic patients

Comorbidity, emergency hospitalizations, A&E visits, moderate and severe dependency, polypharmacy

HEALTH PROMOTION Healthy people

WHO do we like to identify people at risk?

24

Multimorbidity unified data base

Insured data source NIA, demographic data

Diagnosis data base

NIA, tipus_codi, codi, data dx ,UP, tipus_UP

“Contact” data base

NIA, dates contacte ,UP, tipus_UP, urgent, CatSalut, T_act.

MDS-Hospital

MDS-PHC

MDS-MH

MDS-NH

MDS-A&E

Central Registered Insured

Health Problems

Pharmacy (PHC and hospital

provided)

Pharmacy data base

NIA, ATC, data dispensació, unitats, Import

Mortalitat (INE)

Data sources

Divisió d’Anàlisi de la Demanda i de l’Activitat

Clinical Risk Groups and levels of aggregation

Standard aggregation 1.000 groups (CRG) Aggregation in groups

St. 9: High need condition

St. 8: Severe neopl

St. 7: Chronic cond. 3 or more organs

St.. 6: Chronic cond. 2 organs

St. 5: Chronic condit.

St 4: Minor chronic cond. diff. organs

St. 3: Minor chronic cond.

St. 2: Acute condition

St. 1: Healthy

History of Heart Transplant

Metastatic Colon Malignancy

Heart Failure + Diabetes + COPD

HF + Diabetes

Diabetes

Migraine+ Hiperlipidemia

Migraine

Pneumonia

Healthy

1 4

1 4

1 6

1 6

1 4

1 4

1 2

Health Status CRG Basic Severity

In the standard aggregation (health status, basic CRG and level of severity) we obtain a basic information about health status and level of severity in less than 40 groups

Healt

h S

tatu

s

Severity Level

Status 9

Status 8

Status 7

Status 6

Status 5

Status 4

Status 3

Status 2

Status 1

1 2 3 4 5 6

More than 1,000 groups. Too much !!!

Stratification and Emergency admission risk

CRG RSC Identification people at risc

Proactive measures

Classification people at risk

Segmentation for the proactive management of people at risk

Identification and recording at Clinical Record

How does it work the morbidity “grouper”

Population Grouper Classification

(Stratification) Intervention

Follow-up

CRG: Clinical Risk Group

Risk Adjustment per morbidity

Identification Key concepts

Returning population stratified data base

Chronic disease selection Hospitalizations

Risk

ID DM HF COPD Asthma Other: Nº emerg admisssion

Hospital Cumulative days

CRG (status

and severity)

Hospitalization Tax

Mortality Tax

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 criteria Different 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 MORTALITY TAX

HOSPITALI-ZATION TAX

ESTIMATED EXPENSE

% ACCUMU-LATED

Impact distribution of different segments

Different utilization of Stratification

• To adjust models of “per capita” financing, assigning different budget related to morbidity burden in each PHC

• To identify populations and population segments with higher multimorbidity burden and more RISK of.........................: Emergency hospital admission High Cost High pharmacy consumption High mortality Higher Social Services Utilization • To assign “individual” RISK: not yet well calculated, we need more

variables to be included and should accept limitation of these tools • How to incorporate Stratification scores into Information Systems: Visualization and access to Shared Clinical Record and local clinical

record Return of data base to local providers • Validated model in American population or an own national/regional

model ?

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 7/5 • 3 emergency

admissions • Hospitalization Risk

of 35%

PCC/MACA

Included in “CASE MANAGEMENT” Program

CRG and Risk score visualization

PATIENT SELECTION by CRG + Nº emergency admissions last 12 months + Hospitalization RISK next 12 months

Current situation chronic patient avaluation

Indicators Primary Care

Hospital Care

Avoidable Hospital Admissions + -

Home Care program Coverage + -

Health outcomes: good control, process and treatment

++ -

Readmission rate in chronic processes: 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 - -

Fragmented care and fragmented evaluation framework

New evaluation vision: “Triple Aim”

Population

Health

Experience

of Care

Per Capita

Cost

• Health Outcomes Indicators incorporates in evaluation Primary Health Care (PHC) (good control chronic diseases, vaccination..)

• Quality of life

• Satisfaction

• PROM

• Costs

• Service utilization: Avoidable Hospitalizations , Readmissions,…

Evaluation and commissioning of ”Integrated Care”

Proposed future chronic patient indicators

Indicators Primary Care Hospital Care

Avoidable Hospital Admissions ++ ++

Home Care program Coverage ++ -

Health outcomes: good control, process and treatment

++ ++

Readmission rate in chronic processes: 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” assessment ++ ++

New contract 2013: Common PHC-Hospital Targets

37

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

ESPECIFIC TRANSVERSE OBJECTIVES (“TERRITORY”) (20%)

% minimum PCC/MACA with Intervention Plan (“PIIC”)

% minimum PCC/MACA with medication review

% minimum PCC/MACA with post-discharge medication conciliation

Reduction emergency admissions in PCC/MACA

Minimum number participants Expert Patient Program

% minimum COPD patients with spirometry

% minimum PHC with Mental Health integration

Prevalence minimum depresion with “severity” criteria

% minimum patients with depresion with “suicide risk” assessment

Development at local level a consultant virtual office

“Amputation rate” reduction in DM

“Ophthalmology/locomotor “ referral first visits under expected tax

HTA: TA good control

+1,6% last year variation

55,67

59,34

62,14

63,89

65,60

68,60 69,70

50

55

60

65

70

75

Jan 2007 Dec 2008 Dec 2009 Dec 2010 Dec 2011 Dec 2012 Dec 2013

Multidimensional assessment in Home Care


29,05

65,11 68,63

78,43 81,53

88,50 92,40

0

10

20

30

40

50

60

70

80

90

100

Gen 2007 Des 2008 Des 2009 Des 2010 Des 2011 Dec 2012 Dec 2013

Heart Failure: patients treated with ACE


67,64

71,12

72,93

75,09 75,48

77,00 77,60

62

64

66

68

70

72

74

76

78

80

Jan 2007 Dec 2008 Dec 2009 Dec 2010 Dec 2011 Dec 2012 Dec 2013

• Indicators of admissions for every Sector and Primary Health Team • 14 chronic diseases • Benchmarking with different standards among PHT and Hospitals

Servei Català Salut. División de Registros

MSIQ. Quality measures MSIQ: http://146.219.25.61/msiq/index.html

http://146.219.25.61/msiq/index.html

Hospital admissions for ACSC

‘Composite’ avoidable hospital admissions at December 2013

Monthly udpated information!

Includes: COPD, HF, pneumonia, DM complications, asthma, urinary infections, dehidratation, HTA

Availability of evolution of avoidable emergency admissions for ACSC per region / sector / PHC team

Source: MSIQ, Catsalut

−6 % last 24 months

Potentially avoidable hospital admissions for COPD

Decrease by 14,8 % from Dec 2011 to Dec 2013 (24 months)

Availability of evolution of avoidable emergency admissions per region / sector / PHC team

Source: MSIQ, Catsalut

Potentially avoidable hospital admissions for heart failure

Source: MSIQ, CatSalut

Decrease by 2% from Dec 2011 to Dec 2013 (24 months)

Availability of evolution of Avoidable Emergency admissions per Region / Sector / PHC Team

New trend! Increase by 25% from 2006 till 2011

Heart Failure

COPD

Avoidable Emergency Admissions in ACSC

Available information at Primary Health Care Centre level

Diabetes complications

Asthma

30-day readmissions

90-day readmissions

30-day Readmissions per Heart Failure per Hospital area

Expected per capita expenditure

The 1% of top consumers spend 1.701,5M €, the 23% of total cost with an average of 21.540€ per cápita cost The 5% of top consumers, spend 3.783,6M €, 51% of total cost with an average of 9.580€ per cápita cost

Average expenditure (€)

Percentiles related to expenditure

Expected per capita expenditure

Average expenditure (€)

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

AGE

Primary Care

Pharmacy

Emergency admissions

Outpatients clinics

Expected per capita expenditure Average expenditure (€)

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

COPD Diabet. Dement Card. CVA Ment. Cirros. Kidney H. Fail. Neopl. VIH

Primary Care

Pharmacy

Emergency admissions

Outpatients clinics

Hospital admission by diagnostic groups > 70 y.

0 4000 8000 12000 16000

Hipertensió essencial

Deliri, demència i altres trastorns cognitius i

amnèsics

Trastorns del metabolisme hidroelectrolític

Asma

Infeccions i ulcera crònica pell

Diabetis mellitus amb complicacions

Hipertensió amb complicacions i hipertensió

secundària

Pneumònia per aspiració d'aliments o vòmits

Infeccions de vies urinàries

Pneumònia (excloent-ne per tuberculosi i MTS)

Malaltia pulmonar obstructiva crònica i bronquièctasi

Insuficiència cardíaca congestiva

70 and more

Pneumonia

Source: DGPRS. Dep Salut, 2013

COPD

HF

Urinary Infection

Asthma

Diabetes with complications

Large differences in Hospital admission rates by sector (x 1.000 hab) for people over 70 y.

0

20

40

60

80

100

120 Taxa crua

Taxa estandarditzada

2.5. Complex Chronic Patients deployment

▪ To define a stratification model that allows segmentation of the population with chronic diseases with different risk levels. Creating a predictive model that incorporates risk situation at Shared Clinical record.

▪ To design Complex Chronic Patient Care Model (PCC).

▪ To design care model for people with advanced chronic disease.

▪ To define collaborative model between health services and social services: design care a collaborative model, access to “Shared her” by social services and incorporation to it information of common interest, identifying common targets in contracts Department of Health and Department of Social Welfare.

PROGRAMA PREVENCIÓ I ATENCIÓ A LA CRONICITAT

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

Integrated Care in Torbay

PROGRAMA PREVENCIÓ I ATENCIÓ A LA CRONICITAT

Integrated Care Model and Social Services

Mrs Smith in Torbay

Basis for a Social and Health Integrated Care

Plan for Catalonia:

PAISS

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

Catalonian Integrated Care model: Set of elements support Integrated Care

Multi-lever approach: ALL things at the same time

Integrated Care pathway: •Multiprofessional work around Primary Care

•Care Transitions •Residential Care •24/7 model

Joint Assessment + Joint Intervention Plan

Stratification: assessing population needs

Clinical and professional leadership

Governance: Health and Social care Boards

Shared Outcome Framework and joint accountability

Aligned Incentives and Integrated Commissioning

Shared clinical and social care record

Culture and change management

Self-care

ENABLERS

PIAISS Integrated Care project: operational approach

1. Integrated health and social care approach for people with health and social needs, including mental health. 24 / 7

2. Joint caseload, joint assessment and joint intervention plan for risk and vulnerable people with health and social needs

3. Converting high intensive institutional long-term care into home and community care with comprehensive services

4. Primary Health teams as main providers of residential care

5. Population Stratification including social data

6. Integrated/shared ICT: Shared health and social care record

7. Shared Integrated Care Outcome Framework. Triple Aim orientation. Single Commissioning Agency in the future

8. Promotion of bottom up experiences based in PIAISS values and principles

9. Self-management approach.

10.Strong involvement of clinical and professional leadership

60

How to conduct a collaborative model?

Local Operational Plan

Situation analysis (through SWOT analysis or any other methodology for analysing): starting point, barriers, facilitators, opportunities and threats. External and internal analysis.

Planning: defining an action plan, operational objectives, action lines and operationalized and calendarized actions.

Communication and implementation: risk analysis tools as well as control and monitoring tools will be used, transversal implementation considerations such as quality, communication, training will be taken into account.

Assessment: the project’s assessment and monitoring model, as well as participating agents’ responsibilities, assessment commissions and reports to be created should be defined.

61


1. Environmental and internal analysis at local level

Minimum internal and external situation analysis / Identify critical elements enabling the building of proposals to be collected in ‘Local Operational and Functional Plan’ (LFP) / Highly operational guidance and implementability with short terms results.

2. Integrated operational care model

Operational approach promoting common space and time.

3. Define and use a “territorial governance board”

Strategic governing body / steering group / implementing group

4. Define a common porfolio for people/users

Complex Chronic care and dependence / Home nursing and home help service (SAD) / Hospital discharge planning / Institutionalized people / Mental health / Childhood at-risk / Abuse / Active aging, health promotion and disease prevention / Other

62


5. Shared information systems: constructing a new eClinical and Social care record

• Identify the person with the 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 model.

• Access to a minimum set of information and variables of common interest on social field for the Shared Clinical Record of Catalonia (HCCC). Later stage: HCSC fed with input from both health and social parties.

1st stage: generation of a Social Intervention Plan incorporated to HCSC. 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.

63


6. Selection of people based on cross-database and lists of people from social and health areas and stratification (!!!)

7. Definition of guaranteed protected pathways in transitions (discharge planning + post discharge support) among services and in crisis situation and proactive planning.

8. Dependence assessment and recognition procedure optimized with a guaranteed maximum response time.

9. Incorporation and definition of roles and responsibilities of different professional profiles (esp. Social workers working in PHC

10. Accountable professional reference for complex cases.

64


11. Common and transverse Shared/Single Outcome Framework with incentive alignment. Progressive process.

Triple aim vision: health results and good care, service utilization and good perception of care.

12. Definition and implementation of an integrated home care model.

13. Joint action plan for promoting autonomy, active aging, health and well being and disease prevention incorporating the role and collaboration of telecare services.

13. Accessibility solutions and joint technical assistance from a territorial perspective.

14. Incorporation of the third sector.

65

North Ireland is developing and Integrated health and social care record !!!

“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 Social Care

+ Social

“Health and Social” Integrated eCare

Pilot project in pioneer territories

1. Structure: existence Local Functional Plan (LFP) containing a

minimum analysis of situation, action and evaluation proposals

2. Accessibility: time access to Social Services and Primary Health Care

3. Activity:

Minimum number or coverage of users or people attended jointly by

evaluation year

Minimum number of coordination meetings structured and planned

annually

4. Satisfaction of users when covered by program together. Quality of

Life assessment

5. Professional Satisfaction

6. Service Utilization: Avoidable potentially hospitalizations in chronic

diseases, 30-day readmissions,…

Looking for a Shared Outcome Framework to promote Integrated Care with Social Services

®

212 PHT

2 HOSPITAL

316 GROUPS

3191 PARTICIPANTS

233 EXPERT PATIENTS

649 PROFESSIONAL

OBSERVERS

ACTIONS 2006-2013 Source: Programa Paciente Experto Catalunya® 2013

www.gencat.cat/salut/pladesalut

70