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EIP AHA Valencia 2016“Towards an Active and Healthy Ageing “
Emilia-Romagna Region - Reference Site EIP-AHA
A Regional Model to Predict Identify and Manage
Multimorbidity and Frailty
Mirca Barbolini
Valencia 21 June 2016
The Region in a nutshell The Region in a nutshell A
gen
zia
San
itar
ia e
So
cial
e R
egi
on
ale
ResidentPopulation4.5 Million
• Local Health Trusts: 8• Research Hospitals: 4• University-Hospital Trusts &
Hospital Trust: 4+1= 5
A Regional Predictive Model
• Applied to the whole adult population of the Region, to assess the risk of hospitalization:
3 726 380 people •18 y.o. (2012-2014)
• Utilize the regional health/administrative data
• Calculate the Risk Score (10 - very high risk; 1 - low risk).
• High level of statistic accuracy (C= 0.85)
-Care allowances for elderly and disabled-Residential Long-term care-Care for severely disabled-Social service
ü Hospital care
ü Home care service
ü Mental Health Care
ü Pharmaceutical Prescriptions
ü Outpatient specialist care
ü Intermediate care
ü Hospice
ü Emergency services
ü Death registry
Social Care
Demographics
Patient Registry
GPs
Clinical-Administrative Databases
Clinical
Databases
Health Care
Unique patient
identifier
Information Collected
• Chronic Diseases/Multimorbidity
• Pharmaceuticals
• Specialist visits
• Hospitalization
• Home care
• Emergency care
• Adherence to Guidelines
• Quality of care indicators
RISK SCORE
Profiles of Risk
Pathology Registers
Regional Profile of Risk - Other Tools
Hospitalization Risk Profile
Cardiovascular Risk
84%
10%
3,3%
2,7%
Low Risk(< 6%) 3.162.524 Low Risk(< 6%) 3.162.524
Moderate Risk (6-14%) 378.308Moderate Risk (6-14%) 378.308
High Risk (15-24%) 124.589 High Risk (15-24%) 124.589
Very high Risk (•25%) 100.470Very high Risk (•25%) 100.470
Population ≥ 18 y.o. - N= 3,765,891
The Regional Profile of Risk - 2014S
elf
Ma
na
ge
me
nt
Ca
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/D
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M
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Primary Prevention
• Risk Profiles provided to GPs
• Activation of Professional Teams
GPs, Specialists, Nurses, Physioterapists, Social Workers:
a Proactive response…
• Interdisciplinary Paths
Clinical, Appropriateness and Adherence, Health Education…
• Participation
Patients, Caregivers, Associations
Regional State of the Art
80 Community Health Centers
80 Community Health Centers
(Casa della Salute)
10
10 Nurse Managed Community Hospitals
11
228 beds
Community Hospital
12
• unique model• nurse managed• limited number of beds than 30)• clinical responsibility with GPs or Local Health Unit physician• involvement of physiotherapists and careworkers
Type of care• nursing care• rehabilitation (physical, respiratory and cognitive)• promotion of patient empowerment and self-management• care giver training
Integrated Models of Care
Community
Hospitals
Multidisciplinary, Integrated, and Participated Pathways of Care
Integrated
Home-Based Care
Ambulatory
(Nurse-Based)
Care for C
hronic
Diseases
All in One…
Transferability
• Population Identification
• Stratification of the Population
• Risk Profile
• Proactive Care
• Disease/Case Management
Administrative -Health Information Systems
Community Based Organizational Structures
Case della Salute
(http://salute.regione.emilia-romagna.it/cure-primarie)
Antonio Brambilla
For Further Information
16
SOLE / FSE Project
PROFITER Project
ARIA Project
The Emilia-Romagna Commitments 2016
A1 Novel approach for improvement adherence to medical plans, medication and management of Bioresources and Pharma
A3 Sunfrail
B3 Delivering Integrated Care Models
Best Practices
ER - Reference Site Governance
SUNFRAIL
Reference Sites Network for Reference Sites Network for Prevention and Care of Frailty and Prevention and Care of Frailty and Chronic Conditions in Community Chronic Conditions in Community Dwelling Persons Dwelling Persons of EU Countriesof EU Countries
SUNFRAIL Project
Promoted by a network of Italian Reference Sites of the European Innovation Partnership on Active and Healthy
Ageing (EIP-AHA)
3rd EU Health Programme - WP 2014
• To share experiences, good practices and tools
to identify and manage frailty and multimorbidity
• EIP-AHA Initiative (A1, A3, B3)
• Italian Ministry of Health - Mattone Internazionale
PARTNER ORGANISATION ACRONYM
LP1Regione Emilia-Romagna - Agenzia Sanitaria E Sociale
Regionale, Italy(RER-ASSR)
Aster - Societa Consortile Per Azioni, Italy (ASTER)
PP2 Regione Piemonte, Italy (RHAP)
PP3 Regione Liguria, Italy (LIGURIA)
PP4Azienda Ospedaliera Universitaria Federico Il
Campania, Italy
PP5 Centre Hospitalier Universitaire De Toulouse, France (GERONTOPOLE)
PP6 Centre Hospitalier Universitaire Montpellier, France (CHRU)
PP7 Universytet Medyczny W Lodzi, Poland (LODZ)
PP8 Universidad De La Iglesia De Deusto, Spain (DEUSTO)
PP9Regional Health & Social Care Board Of Northern
Ireland, United Kingdom (HSCB)
PP10European Regional And Local Health Authorities Asbl,
Belgium(EUREGHA)
The Partnership
§ Alsace§Languedoc-Roussillon§ Paris • Pays de la Loire F
§ Ireland (COLLAGE)IE
§Merseyside§ Northern Ireland• S.W. Scotland• Wales§ Yorkshire and the Humber
UK
§ Gelderland and Overijssel§ Noord-Brabant§ Northern Netherlands§Zuid-Holland§Twente Region
NL
§ Andalucia§ Catalunya§ Galicia§ Región de Madrid§País Vasco§ Valencia-La Fe
E§ Centro (Uni Coimbra)
PT
§ Region Skåne SE
§ City of Oulu FI
§ Czech RepublicUni Hospital Olomuc
CZ
§ Sothern Danemark
DK
§ Liguria§ Campania§ Emilia-Romagna§ Friuli Venezia Giulia§ Piemonte
IT
§ Saxon State DE
Source: European Commission. Excellent Innovation for Ageing - a European guide: the Reference sites of the European Innovation Partnership on Active and Healthy Ageing. 2013
EIP-AHA Reference Sites
Synergies with the Ongoing EIP-AHA Initiatives
SUNFRAILGeneral Objectives
To improve the identification, prevention and management of frailty and
care of multimorbidity in community dwelling persons (over 65) of EU
countries.
Specific Objectives
1. To design an innovative, integrated model for the prevention and management of frailty and care of multimorbidity (outcomes of the EIP-AHA).
2. To validate the model: assess existing systems and services targeting frailty and multimorbidity – citizen’s/patient’s needs.
3. To assess the potential for the adoption/replication and sustainability of the model (good practices) in different organizational contexts.
4. To promote the dissemination of the results (decision makers - regional, national, EU level).
RegionReference Site
Frailty Dimensions
Chronic conditions
Multi morbidity
Adherence therapy
Falls Prevention
Social Economical
…
#1
#2
#3
#4
#..
Activities/Best practices
Reference Sites Systems Reflecting Frailty
Frailty: Areas Challenging Health Care Services
Primary prevention/Early Detection
a) Screening the population for frailty using both quantitative or qualitative approaches
Diagnosis a) Identification and evaluation of frail and pre-frail patients
Secondary prevention/Care a) Management of frailty progression
Emergency/Hospitalization a) Management of hospitalized frail patients
Building Capacity/professionals/social network
a) Improving "Patient Centered Care"
Different Possible Models Different Possible Models
Diagnosis
Prevention
Management in-hospital
Management out-hospital Educational
Patient
Frailty Ecosystem for each Reference Site
SocialTreatment guidelines
Economical
[…]
Main OutcomesOperational Definition of Frailty and Pre-Frailty
Biomedical
- Biological: Age, sex
- Health-diseases
- Life Styles: physical
activity, nutrition...
- Risk Factors: smoke,
alchool..
- Family network
Loss = Pre-Frailty??
Psycosocial•Well being (physical, psychological)
•Independent living•Socialization•Resources: health care, social interaction, sport, leisures
Frailty or Pre-Frailty??
Biomedical vs. Bio-Psychosocial Model
Criteria of Inclusion?
Perceived/Expressed Needs?
Main Outcomes
• A shared model-good practices on frailty and multimorbidity
• A tool kit for the prediction of frailty and multimorbidity:
Primary care
-Instruments to assess the risks of frailty: physical, cognitive, nutritional and psycosocial conditions (biomedical,individual, socio-economic dimensions)
-to support the adoption of care pathways (early detection, management)
Integrated care
-methods and instruments to predict multimorbidity
Other tools:
-Instruments for professional’s capacity building
-Analysis of costs
PARTICIPATION OF ITALIAN REFERENCE SITES TO THE JOINT ACTION ON FRAILTY
Main Objectives•Engage in mutual learning on the identification, prevention and management of pre-frailty and frailty (physical, cognitive, nutritional, socioeconomic, behavioral domains) (synergy with Sunfrail/other projects)
•Disseminate the outcomes of the JA and GPs emerging from Sunfrailproject and related EIP-AHA initiatives involving Regions and relevant stakeholders of the EIP-AHA and beyond
Participation of Italian Regions - Mattone Internazionale•WP2 (Dissemination) (R. Marche-Leader)•Other WPs
:
REGIONE MARCHE
Regional Thematic Priorities for EU Projects
i Population Ageing and Related Conditions: Frailty and
Multimorbidity
i Primary Health and Social Care - Multidisciplinary -Integrated Care
i Early Detection, Prevention and Management of Chronic Diseases
i Impact Assessment (Clinical - Economic)
i Infectious Diseases: Information and Surveillance
i Mental Health: Promotion and Prevention
Thank you for your attention!Thank you for your attention!
www.sunfrail.euwww.sunfrail.eu
Mirca BarboliniMirca [email protected]@regione.emilia--romagna.itromagna.it