1. Basis for a Social and Health Integrated Care Plan for Catalonia: PIAISSPIAISS The journey from a Chronic Care Program towards a new model of Integrate health and social care

2. Session structure A new Health Plan and the introduction of a new STORY Chronicity Prevention and Care Program: the journey toward Integrated Care Complex Chronic Care Program Towards a new evaluation framework: The first results A new journey toward a new Integrated health and social care model ICT developments to support new Integrated Care model 3. 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 4. 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 5. Public System Network: 369 Primary Care Teams (827 local health centers) 69 Acute care hospitals (14,072 beds) 96 Long-term care centers 41 Mental health care centers Healthcare data figures 6. Catalan Healthcare System U S E R U S E R SERVEI CATAL DE LA SALUT 100% SERVEI CATAL DE LA SALUT 100% SUPLEMENTARY PRIVATE INSURERS 20% SUPLEMENTARY PRIVATE INSURERS 20% INSTITUT CATAL SALUT (public) 20% INSTITUT CATAL SALUT (public) 20% PRIVATE CENTERS 10% PRIVATE CENTERS 10% CONTRACTED NON-PROFIT PROVIDERS 70% CONTRACTED NON-PROFIT PROVIDERS 70% Commissioner Provision 7. An increasing number of elderly Source: INE, projections 2011 1/3 of population will be over 65 and 12% will be over 80 8. 3.5.1. Hospital beds per 1000 population, 2010 and change between 2000 and 2010 2010 (or nearest year) Germany Austria Hungary Czech R. Lithuania Poland Bulgaria Belgium France Slovak Republic Romania Finland Luxembourg Estonia Latvia EU-27 Greece Netherlands Slovenia Malta Cyprus Italy Denmark Portugal Spain Ireland United Kingdom Sweden Iceland Croatia Serbia Switzerland FYR of Macedonia Montenegro Norway Turkey Source: OECD Health Data 2012; Eurostat Statistics Database; WHO European Health For All Database. Germany Austria Finland France Number of hospital beds in OCDE Spain EU-27 United Kingdom Sweden 9. Hospital discharges in OCDE countries Source: OECD Health Data 2012; Eurostat Database; WHO European Health For All Database. 10. 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 oriente d towards chronic patients 3. A more responsive system from the first levels 4. System with better quality in high-level specialties 11. Strategic lines of the program 12. 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 Other 6 conditions to be included in the future 12 Integrated Care Pathways 13. 212 PHT 2 HOSPITAL 316 GROUPS 3191 PARTICIPANTS 233 EXPERT PATIENTS 649 PROFESSIONAL OBSERVERS EXPERT PATIENT PROGRAM 2006-2013 Source: Programa Paciente Experto Catalunya 2013 14. METHODOLOGY Source: Programa Pacient Expert ICS 2006 15. 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 16. Healthy 33% Chronic non complex 62% Complex 3,5% Advanced 1,5% Terminal Bereavement PREVENTIVE APPROACH CURATIVE APPROACH PALLIATIVE APPROACH SELFCARE COLLABORATIVE CARE Integrated Clinical and Care Pathways 17. 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 Taking care of complex patients 18. 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 19. 19 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 dispensaci, unitats, Import Mortalitat (INE) Data sources Divisi dAnlisi de la Demanda i de lActivitat 20. Multimorbidity in Catalonia 21. DM2 COPD DEPRE OSTEOARTHRITIS Prevalence of comorbidity Heart Failure 22. 22 PCCMultimorbidity Severe unique disease Advanced frailty MACALimited live prognosis Palliative approach, Advance care planning Two profiles of complexity 23. -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 24. 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 25. 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 26. Initial Health Plan target(!): 25.000 complex chronic patients should be identified by 2015 At April 2014 over 90.000 patients included Evolution of PCC / MACA with a collaborative intervention plan in shared IT Labeling available since January 2013 ! 27. Shared Individual Intervention Plan (PIIC) Health problems/Diagnosis Active Medication Allergies Recommendations for in case of crisis or exacerbation Advanced Care Planning Resources and services used Multidimensional assessment Carer whom are delegated decisions Additional information of interest 28. 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 29. A NECPAL Questionnaire is available to assess Advanced Chronic Disease Condition Surprise question (!): Would you (the referee clinician) be surprised that patient could die in the next following 12-18 months? Al least another clinical condition indicating bad prognosis 30. Clinician could create a Plan according chronic conditions and related variables available to perform follow-up 31. 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? 32. 32 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 dispensaci, unitats, Import Mortalitat (INE) Data sources Divisi dAnlisi de la Demanda i de lActivitat 33. Clinical Risk Groups and levels of aggregation Standard aggregation 1.000 groups (CRG) Aggregation in groups 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 HealthStatus 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 !!! 34. 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 35. How does it work the morbidity grouper Population Grouper Classification (Stratification) Intervention Follow-up CRG: Clinical Risk Group Risk Adjustment per morbidity IdentificationKey conceptsKey concepts 36. Returning population stratified data base Chronic disease selection Hospitalization s Risk ID DM HF COPD Asthma Other: N emerg admis ssion Hospital Cumulat ive days CRG (status and severity) Hospitaliz ation 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 37. 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 38. 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 ? 39. Visualization in Shared Clinical Record and different RISK scores Morbidity group and RISK calculated and published twice a year Description of different RISK segments 40. 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 41. PATIENT SELECTION by CRG + N emergency admissions last 12 months + Hospitalization RISK next 12 months 42. Who are the PCC and MACA patients ? Source: CatSalut, 2013 PCC MACA 43. Who are the PCC and MACA patients ? Source: CatSalut, 2013 Distribution of emergency admissions 1 chronic condition 2 chronic conditions 3 chronic c. Cancer Other high demanding c. 44. Constructing a new Morbidity Grouper in Catalonia: emergency admission distribution Source: CatSalut, 2013 No urgent hospitalization 45. 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 46. 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 ? 47. Trend in Quality Measures: increasing interest of Coordination Area 48. New contract 2013: Common PHC-Hospital Targets 48 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 49. Information System Tool for Managers in Primary Health Care Screen where you could monthly monitor health indicators available for Primary Care managers 50. SISAP: Professionals System Information Screen display of indicators by doctors and nurses. (!) Monthly data updated !!! Differentiated internal weight among indicators You MUST identify an expected prevalence Comparison with Team and all organization 51. List of patients in bad control Clinician could edit and print list of patients who could benefit of an intervention for every health indicator to act proactively Information System Tool for GPs and Community Nurses in Primary Health Care 52. HTA: TA good control +1,6% last year variation 53. DM: Good metabolic control +2,8% last year variation 54. Multidimensional assessment in Home Care +4,4% last year variation 55. Heart Failure: patients treated with ACE +0,8% last year variation 56. HIS is progressing towards a patient-centered model It searches information collected earlier and available in the system It proposes actions related to the current conditions and multimorbidity profile It is a tool to facilitate prevention, diagnosis and follow-up to deal with long-term conditions It is a part of a whole and integral follow-up model Inteligncia Activa (Active Intelligence) 57. Els agrupadors CRG grau/gravetat CRG Morbidity Group and number or previous emergency admissions Individual proposal per patient, created assessing needs of each patient All patient information with a click: Clinical follow-up, / Lab and other test results / Clinical Guidelines / Vaccinations / Terapeuthical guidelines / Diagnosis / Morbidity Groups,... Inteligncia Activa (Active Intelligence) 58. WARNINGS and ALERTS Discharge Planning / RX / Lab results 59. List of patients sorted by gaps ID PACIENT GAP 60. Panel Management: Alert and Warnings screens 60 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 ! 61. Indicators of admissions for every Sector and Primary Health Team 14 chronic diseases Benchmarking with different standards among PHT and Hospitals Servei Catal Salut. Divisin de Registros MSIQ. Quality measures MSIQ: http://146.219.25.61/msiq/index.html 62. Hospital admission by diagnostic groups > 70 y. Source: DGPRS. Dep Salut, 2013 COPD HF Urinary Infection Asthma Diabetes with complications 63. Hospital admissions for ACSC 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 (x 100.000 inhab. Tax) Source: MSIQ, Catsalut 6,5 % last 24 months 64. Potentially avoidable hospital admissions for COPD Decrease by 13,1 % from Dec 2011 to Dec 2013 (24 months) Availability of evolution of avoidable emergency admissions per region / sector / PHC team (x 100.000 inhab. Tax) Source: MSIQ, Catsalut 65. Potentially avoidable hospital admissions for heart failure Source: MSIQ, CatSalut Decrease by 3 % from Dec 2011 to Dec 2013 (24 months) Availability of evolution of Avoidable Emergency admissions per Region / Sector / PHC Team (x 100.000 inhab. Tax) New trend! Increase by 25% from 2006 till 2011 66. Differences in standarized Avoidable emergency admissions in Spain Source: Abadia MB. Atlas Variabilidad Hospitalizaciones Potencialmente evitables, 2011 COPD HEART FAILURE 67. Large differences in emergency hospital admission rates by sector (x 100.000 inhab) Catalan average: 971 x 100.000 inh. 68. Large differences in emergency hospital admission rates by sector after adjustment 69. Differences in 30-day readmission rates by sector Catalan average: 10,78% 70. Readmission rates by sector after adjustment 71. Heart Failure COPD Avoidable Emergency Admissions in ACSC Available information at Primary Health Care Centre level Diabetes complications Asthma Accessible by Primary Care Directors 72. 30-day readmissions 90-day readmissions 30-day Readmissions per Heart Failure per Hospital area 73. 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 cpita cost The 5% of top consumers, spend 3.783,6M , 51% of total cost with an average of 9.580 per cpita cost Average expenditure () Percentiles related to expenditure 74. Expected per capita expenditure Average expenditure () Primary Care Pharmacy Emerg.adm. A&E Outpatient Clinics AGE Primary Care Pharmacy Emergency admissions Outpatients clinics 75. Basis for a Social and Health Integrated Care Plan for Catalonia: PIAISSPIAISS 76. 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 77. Integrated Health and Social Care is high priority in England: Integrated Care value case toolkit is developed http://www.local.gov.uk/web/guest/health/-/journal_content/56/10180/4060433/ARTICLE 78. Direcci dAtenci Primria Costa de Ponent 79. Integrated Care Model and Social Services Mrs Smith in Torbay 80. What does Mrs.Smith want? 81. 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 82. Catalonian Integrated Care model: Set of elements support Integrated Care Multi-lever approachMulti-lever approach: ALL things at the same time: 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 83. Emergency admissions tax related to COPD exacerbation More than a half emergency admissions compared to Catalan average (x 100.000 inhab. Tax) 84. More than a half emergency admissions compared to Catalan average (adjusted data) Emergency admissions tax related to COPD exacerbation 85. Emergency admissions tax related to HF exacerbation Almost half emergency admissions compared to Catalan average (x 100.000 inhab. Tax) 86. More than a half emergency admissions compared to Catalan average (adjusted data) Emergency admissions tax related to HF exacerbation 87. Emergency admissions tax related to diabetes complications Almost half emergency admissions compared to Catalan average (adjusted) (x 100.000 inhab. Tax) 88. 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 projects assessment and monitoring model, as well as participating agents responsibilities, assessment commissions and reports to be created should be defined. 89. How to conduct a collaborative model? 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 90. How to conduct a collaborative model? 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 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. 91. North Ireland is developing and Integrated health and social care record !!! 92. 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 CareHealth Care Social CareSocial Care + Social Health and Social Integrated eCare Pilot project in pioneer territories 93. How to conduct a collaborative model? 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. 94. How to conduct a collaborative model? 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 home aids stores from a territorial perspective. 14. Incorporation of the third sector. 95 95. 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 96. ICT Strategy in The Catalan HealthCareand SocialCare System ICT Services 97. TicSalut Foundation Shared Electronic Health Record (eHR) end Personal Health Folder (PHF) iSIS.Cat. Integrating Health and Social Care 1 2 3 98. TicSalut: Technology, Innovation & Health Founded in 2006, TicSalut Foundation is an agency within the Catalan Department of Health that works to promote the development and use of ICT in the health and social care domain, acts as a trends, innovations and emerging initiatives observatory, and provides services for the standardisation and accreditation of products. 99. TicSalut, a responsibility to innovate Advancing Knowledge Transfer in the Region Providing an Innovation Observatory in the HealthCare domain Standardizing Interoperability Managing the demand for Innovation across the whole HealthCare system Promoting Innovation in HealthCare 100. 97%97% Hospitals 98%98% Primary Care 82%82% Long-term care 67%67% Mental health Catalonia Spain USA 27 hospitals 6 EMRAM December 2013 Current Situation in December 2013 101. Shared eHR and PHC There are two key elements to develop ICT according to the objectives of the Health plan: Electronic Health Record of Catalonia (eHR) Personal Health Channel It allows organized access to relevant information of different centers health records and to some central databases of the health system. The eHR is not the sum of the electronic records of the healthcare centers; it doesnt incorporate all the information from medical records. The citizen is the holder of the data contained in its medical record He will have access to its health information available in its electronic Health Record As an information and services network Deployment of a multichannel network to communicate and interact with the citizen 102. 1.8m docs/month 23% Current model 121.390 access/month 64% New model BPM Rules CDSS IS Web services Care processes Health intelligence Messaging platform BI/visor Future model: ISISS.cat Health and social integration Healthcare processes integration Challenging EVOLUTION 103. Shared Clinical Record (HCCC) to share among organizations common clinical information: diagnoses, prescriptions, vaccinations, hospital discharge reports,... 104. 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) 105. Folder Information Digital certificate Documents Channel Communication Robust password Services CITIZENS ACCES TO DATA 106. Home Diagnosis ePrescription Vaccination Connect My controlsReports Search by: - Report type - Date - Center PHC: Clinical reports 107. Online: always updated Printable PHC: ePrescription Available and printable medication and chronic treatment Hom e Diagnosis ePrescription Vaccination Connect My controls Report s 108. Reported from provider center Reported from vaccination book Reported verbally from patient Duplicated PHC: Vaccination and Reports vaccines supplied Hom e Diagnosis ePrescription Vaccination Connect My controls Report s 109. i-SISS.Cat Strategic plan for the implementation and deployment of the platform for the management of healthcare and social care Processes in Catalonia 110. 111 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 The i-SISS.Cat solution should allow: 111. Courtesy of: Mr. Jordi Martnez Chief Innovation Officer, TicSalut Foundation jmartinez@ticsalut.cat 112. gencat.cat