Because everyone matters. IBM Health and Social Programs Summit, October 2014 Chronic and Integrated Care in Catalonia Catalonian Department of Health-TICSalut Mr. Juan Carlos Contel Dr. Jordi Martínez

1. 1
Chronic and Integrated
Care in Catalonia
Mr. Juan Carlos Contel
Dr. Jordi Martínez
Catalonian Department of
Health-TICSalut

2. Basis for a Integrated Health and Social Care Plan for
Catalonia:
From PPAC to PPIIAAIISSSS
The journey from a Chronic Care Program
towards a new model of Integrate health
and social care
Washington, October 20th 2014

3. 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
• Care management as strategy
• 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. “i-SISS.cat” contribution
3

4. 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

5. 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,
palliative care)
• 41 Mental Health Centres
5

6. Catalan Healthcare System
USER
USER
Commissioner Provider
SERVEI
CATALÀ
SERVEI
CATALÀ
DE LA SALUT
DE LA SALUT
100%
100%
SUPLEMENTARY
SUPLEMENTARY
PRIVATE
INSURERS
PRIVATE
INSURERS
20%
20%
INSTITUT
CATALÀ
SALUT
(public)
INSTITUT
CATALÀ
SALUT
(public)
77%
77%
CONTRACTED NON-PROFIT
CONTRACTED NON-PROFIT
PROVIDERS
23%
PROVIDERS
23%
PRIVATE
CENTERS
10%
PRIVATE
CENTERS
10%
6

7. The Catalan Health Plan 2011-2015
Launched at the end 2011
1. Objectives and health programs
5. Greater focus on the patients and families
6. New model for contracting health care
7. Incorporation of professional and clinical knowledge
8. Improvement of the government and participation in the system
9. Improvements to information, transparency and evaluation
Source: 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.
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
7

8. Strategic lines of the Chronic Care Program
8

9. 9
An increasing number of elderly
1/3 of population will be over 65
and 12% will be over 80
Source: INE, projections 2011
9

10. Integrated Clinical and Care Pathways
Healthy
33%
Chronic non
complex
62%
Complex
3,5%
Advanced
1,5% Terminal Bereavement
PREVENTIVE APPROACH
CURATIVE APPROACH
PALLIATIVE APPROACH SELFCARE
COLLABORATIVE CARE
10

11. Integrated Care Pathways
• 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
11

12. 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
12

13. WHO do we like to identify people at risk?
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
13

14. 14
Two profiles of complexity
PCC
Multimorbidity
Severe unique disease
Advanced frailty
MACA
Limited live prognosis
Palliative approach,
Advance care planning
Basic and Priority: “PCC” and “MACA” identification and labelling +
Integrated Care Pathway + 24 / 7 model + Carer identification and support
14

15. PCC: Complex Chronic
Patient
MACA: Advanced chronic
disease
- 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)
15

16. Information from Centres/Hospitals
Primary Care
Specialist Care
Diagnostic
Procedures
Diagnostics
Prescriptions
Vaccination
Hospital Discharge Report
A&E Report
Specialist Care Report
Lab Results
RX Report
Other diagnostic reports
Information from Dep of Health
Hospital Data
Electronic
Prescription
Diagnoses
Procedures
Discharge Data
Prescription
Medication Plan
“Shared Clinical Record (HC3)
16

17. “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

18. 18
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.
Data sources
Central Registered
Insured
Health Problems
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-A&E
Pharmacy (PHC and
hospital provided)
Pharmacy data base
NIA, ATC, data dispensació, unitats,
Import
Mortalitat (INE)
Divisió d’Anàlisi de la Demanda i de l’Activitat 18

19. Clinical Risk Groups and levels of aggregation
Standard aggregation  1.000 groups (CRG)
Health Status
1 2 3 4 5 6
Severity Level
Status 9
Status 8
Status 7
Status 6
Status 5
Status 4
Status 3
Status 2
Status 1
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
More than 1,000 groups. Too much !!!
Aggregation in groups
19

20. Multimorbidity in Catalonia obtained by stratification
20

21. Prevalence of multimorbidity
DM2 COPD
DEPRE
Heart Failure
OSTEOARTHRITIS
21

22. 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
22

23. Returning population stratified data base
Chronic disease selection
Hospitalizations
Risk
ID DM HF COPD Asthma Other: Nº
emerg
admisssi
on
Hospital
Cumulative
days
CRG (status
and
severity)
Emergency
admission
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 criteria
Different pyramids related to different Risk approach:
Future hospitalization / Death / Future cost
23

24. Impact distribution of different segments
POPULATION MORTALITY
RATE
HOSPITALI-ZATION
RATE
ESTIMATED
EXPENSE
% ACCUMU-LATED
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%
24

25. Constructing a new GMA morbidity grouper in Catalonia
Mortality PHC contacts Hospitalization A&E use
CRG vs GMA CRG vs GMA CRG vs GMA CRG vs GMA
Source: CatSalut, 2013
25

26. 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 assessments
26

27. 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
27

28. Who are the PCC and MACA patients ?
PCC MACA
Source: CatSalut, 2013
28

29. Who are the PCC and MACA patients ?
Distribution of emergency admissions
Source: CatSalut, 2013
1 chronic
condition
2 chronic
conditions
3 chronic c. Cancer Other high
demanding c.
29

30. Current situation chronic patient avaluation
Fragmented care and fragmented evaluation framework
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 - -
30

31. New evaluation vision: “Triple Aim”
Population
Health
Experience
of Care
• Health Outcomes Indicators
incorporates in evaluation Primary
Health Care (PHC) (good control
chronic diseases, vaccination..)
Per Capita
Cost
• Quality of life
• Satisfaction
• Patient Reported Outcome
Measures (PROM)
• Costs
• Service utilization: Avoidable
Hospitalizations , Readmissions,…
Evaluation and
commissioning of
”Integrated Care”
?
31

32. Professional & Managerial System Information
You MUST identify an
expected prevalence
Benchmark with
Team and all
organization
Screen display of indicators by doctors and nurses. (!) Monthly
data updated !!! Differentiated internal weight among indicators

33. New contract 2013: Common PHC-Hospital Targets
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 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 33 under expected tax
33

34. Figures: Hospital admissions for chronic conditions
Availability of evolution of avoidable emergency admissions for a
range of chronic conditions per region / sector / PHC team
(x 100.000 inhab. rate)
720
710
700
690
680
670
660
650
640
630
Includes: COPD, HF, DM complications, asthma, coronary diseases, HTA
Monthly udpated information!
Source: MSIQ, Catsalut
709,6
684,1
652,7
620
2011 2012 2013
8 %
last 24
months
34

35. Figures: Potentially avoidable hospital admissions for
COPD
Availability of evolution of avoidable emergency admissions per
region / sector / PHC team (x 100.000 inhab. Tax)
Decrease by 13,1 % from Dec 2011 to Dec 2013 (24 months)
Source: MSIQ, Catsalut
35

36. Figures: Potentially avoidable hospital admissions for
heart failure
Availability of evolution of Avoidable Emergency admissions per
Region / Sector / PHC Team (x 100.000 inhab. Tax)
Decrease by 3 % from Dec 2011 to Dec 2013 (24 months)
New trend!
Increase by
25% from 2006
till 2011
Source: MSIQ, CatSalut
36

37. Basis for a Social and Health Integrated Care Plan for
Catalonia:
PPIIAAIISSSS

38. 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
38

39. Integrated Health and
Social Care is high
priority and policy in EU
(ex: England, Scotland,
etc.)
https://www.gov.uk/government/policies/making-sure-health-and-social-care-services-work-together
39

40. 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: joint caseload
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
40

41. 1
HHIIGGHH HHEEAALLTTHH
AANNDD SSOOCCIIAALL
CCOOMMPPLLEEXXIITTYY
COMPLEX SOCIAL NEEDS
Complex health
and social needs ?
COMPLEX HEALTH NEEDS
2
5 4
COMPLEX HEALTH AND
SOCIAL NEEDS
6 7
3
RRIISSKK TTOO DDEEVVEELLOOPP CCOOMMPPLLEEXX HHEEAALLTTHH AANNDD SSOOCCIIAALL NNEEEEDDSS
41

42. How to conduct a collaborative model?
5. Shared information systems: constructing a “new Health & Social”
electronic 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 (HC3). 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.
42

43. “Health and Social” Integrated eCare
Pilot project in pioneer territories
Diagnostics/ Health
problems
“PCC / MACA”
condition
Shared Individual
Intervention Plan
(“PIIC”)
“Dependency degree”
formal assessment
“Home Help”
services label
“Telecare” services
label
Social Care
Intervention Plan
Pharmacy
prescription
+ Social
HHeeaalltthh CCaarree SSoocciiaall CCaarree
43

44. 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 for people with complex needs
44

45. 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.
45 45

46. Catalonian Integrated Care model:
Set of elements to support Integrated Care
“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
Clinical and professional
leadership
Stratification models: assessing
population needs
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 Empowerment and
Self-care
ENABLING ELEMENTS
Culture and change
management
MMuullttii--lleevveerr aapppprrooaacchh:: AALLLL tthhiinnggss aatt tthhee ssaammee ttiimmee

47. Decentralized System Action to call - Challenges
Catalan System
The Catalan healthcare is a multi-provider
model integrated in a unique public network.
Providers are free to select their information
systems; however 85% of the primary care
centers have the same system (eCAP)
Interoperability among systems must be
guaranteed
Integrated care (health & social)
47

48. Action to call - Challenges
There are two key elements to develop ICT according to the objectives
of the Health plan:
Electronic Health Record of Catalonia (EHR)
As an information and services network
• 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 doesn’t
incorporate all the information from medical records.
Personal Health Channel
Deployment of a multichannel network to communicate and interact with the
citizen
• 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
48

49. 9977%%
Hospitals
9988%%
Primary
Care
8822%%
Long-term
care
6677%%
Mental
health
Catalonia
Spain
USA
27 hospitals 6
EMRAM
2013
Action to call - Challenges

50. 64%
2 m docs/month
23%
Current model
121.390 access/month
BI/visor
BPM
Rules
CDSS
IS
Health intelligence
Care processes
Web services
Messaging
platform
New model: ISISS.cat
Health and social integration
Integrated care
processes
Action to call – i-SISS.Cat

51. i-SISS.Cat
Strategic plan for the implementation and
deployment of the platform for the management
of healthcare and social care Processes in Catalonia

52. 52
The i-SISS.Cat solution should allow:
Citizen
Access to healthcare & social
information
Provide different services to
interact with the system
Personalize assistance
Patient expert communities
and e-learning contents
Healthcare & Social System
Accelerate implementation of healthcare strategy plan
Allow to transform healthcare model (from Activity
towards Outcomes)
Analytics tools for the governance model
Allow process standardization
Social & Healthcare
Providers
Interoperate with the rest of
providers
Facilitate the adoption of new
payment models
Implement clinical pathways in
every region
360 vision of patient
Manage the processes and
KPIs measurement
Collaboration environments

53. The i-SISS.Cat solution challenges:
Government programs:
Summary of
Processes
Governance
i-SISS.Cat
•Creation of programs and tracking key
performance indicators (KPIs).
•Display of results for program and service
provider.
360 °view of the patient:
• Access to the broad view of the patient and
the process
•Environments of collaboration between
professionals.
Healthcare process integration:
• Shared Social and health-related
information
•MDT platform
Integral vision of the citizen: • Platform that will allow us to expand the
coverage to other social benefits and giving
coverage to the unique social and health record.
53

54. 54
The i-SISS.Cat solution integrated care:
Actions:
•Priorisation of
chronic conditions
groups
•KPIs definition at
high level
•360º vision
design per
program
•Interoperability
standards
Roadmap i-SISS.Cat
Outcome
Measurement
Patients
enrollment
Pathways
Implementation and
EHR integration
Integrated
Pathways
definition
Program
creation
and KPIs
Actions:
•Pathway
definition and KPIs
•Definition of
recommendations
Actions:
•Technical
development to
facilitate data
flow and
exchange from
different
providers
•Configuration of
roles for users
Actions:
•Information
exchange
•360º vision
•Alerts definition
•Creation of a
collaborative
environment
•Patient
monitorization
Actions:
•Predictive
modeling
•Query
utilities to
select patients
at risk
•Support
decision tool
ACHIEVED IN PROGRESS

55. The i-SISS.Cat solution overview:
Previous experience in integrated care processes: MECASS
Project (based on Cúram)
55

56. 360 holistic vision of patient
•Patient Segmentation and Stratification
relevant information (CRGs, labels, etc.)
•Clinical Data per program
•Resource consumption for each Plan
•Program cost (plan vs. real)
56
The i-SISS.Cat solution areas:
Global treatment plan
•Access to services and different units for
program & provider – best provider for the job
• Integrated activities in a patient workspace
(interoperability)
•Provider billing process based on results /
success

57. The i-SISS.Cat solution areas:
Multidisciplinary Team
environment:
•Agreed patient treatment – meeting
minutes
•Agenda shared for scheduling
meetings
•Share information and knowledge
•Open discussions about the patient:
treatment, etc.
•MDT meetings management
57

58. 58
The i-SISS.Cat solution areas:
Measure the impact of each
program defined
•Global results: efficiency of
program – impact on resources
•Impact in the healthcare system
•Impact in the patient health
•Cost – Benefit analysis
•Increase the quality of service:
patient perception

59. 59
The i-SISS.Cat solution roadmap:
2016
2014
Kick Off
Interoperability
platform
First process definition
(PCC)
Measure KPIs
2017-2018
2015
Deployment of services
for the citizen
Models advanced
analysis, prediction and
knowledge management
Third wave of process
definition
Measure KPIs
Continuous
improvement and
calibration
New processes within
the model
System deployed to all
the country
Measure KPIs
Goal to achieve: a modular solution, that
allows to implement the strategic objectives
defined in the Health Plan 2011 - 2015
Go Live of integrated
process solution
Opening the door to the
citizen
Integration of health
and social process
Second wave of process
definition
Measure KPIs

60. 60
The i-SISS.Cat solution roadmap:
2016
2014
Kick Off
Interoperability
platform
First process definition
(PCC)
Measure KPIs
2017-2018
2015
Deployment of services
for the citizen
Models advanced
analysis, prediction and
knowledge management
Third wave of process
definition
Measure KPIs
Continuous
improvement and
calibration
New processes within
the model
System deployed to all
the country
Measure KPIs
Goal to achieve: a modular solution, that
allows to implement the strategic objectives
defined in the Health Plan 2011 - 2015
Go Live of integrated
process solution
Opening the door to the
citizen
Integration of health
and social process
Second wave of process
definition
Measure KPIs

61. Basis for a Integrated Health and Social Care Plan for
Catalonia:
From PPAC to PPIIAAIISSSS
Thank you very much for your attention!!!
Washington, October 20th 2014

62. Chronic and Integrated Care in
Catalonia
Catalonian Department of Health-
TICSalut
Mr. Juan Carlos Contel
Dr. Jordi Martínez

63. BACK UP SLIDES

64. IMPLEMENTATION SUPPORTING GUIDE
NUCLEAR CARE MODEL
Source: PPAC 2013. Departament de Salut
NEW
INDIVIDUAL
ACTIONS
TEAM
REDESIGN
TERRITORY
COMPLEXITY
CARE
PATHWAY
Excellence
Optimal
provision
Basic
requirements
64

65. 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

66. Visualization in Shared Clinical Record and
different RISK scores
Morbidity group
and RISK calculated
and published twice
a year
Description of
different RISK
segments

67. CRG and Risk score visualization
CRG information (morbidity
CRG information (morbidity
group), severity and
Hospitalization Risk
group), severity and
Hospitalization Risk
• CRG 7/5
• 3 emergency
admissions
• Hospitalization Risk of
35%
PPCCCC//MMAACCAA
Included in “CASE
Included in “CASE
MANAGEMENT” Program
MANAGEMENT” Program

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

69. Ad-hoc “queries”:
Every professional could perform
a basic query combining
stratification and current chronic
conditions and other variables
(pharmacy,…)
Stratification segment code
It could be selected 1 or
more chronic conditions

70. List of patients sorted by “gaps”
ID PACIENT “GAP”

71. New “panel management”introduced
71
•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 !

72. 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

73. MSIQ. Quality measures
MSIQ: http://146.219.25.61/msiq/index.html
Servei Català Salut. División de Registros
• Indicators of admissions for every Sector and Primary Health Team
• 14 chronic diseases
• Benchmarking with different standards among PHT and Hospitals

74. Hospital admissions for ACSC
Availability of evolution of avoidable emergency admissions for ACSC
per region / sector / PHC team (x 100.000 inhab. Tax)
−6,5 %
last 24
months
Includes: COPD, HF, pneumonia, DM complications, asthma, urinary infections, dehidratation, HTA
Monthly udpated information!
Source: MSIQ, Catsalut

75. Avoidable Emergency Admissions in ACSC
COPD
Heart Failure
Available
information at
Primary Health
Care Centre level
Diabetes
complications
Asthma

76. 30 and 90 day Readmissions per Heart Failure per area
30-day readmissions
90-day readmissions

77. Variability Atlas related to indicators
Source:Evaluation and Quality Agency
Population based related
to Primary care area

78. Expected per capita expenditure
Average expenditure (€)
Outpatients clinics
Emergency admissions
Pharmacy
Primary Care
AGE
Primary Care Pharmacy Emerg.adm. A&E Outpatient Clinics

79. Expected per capita expenditure
Average expenditure (€)
Outpatients clinics
Emergency admissions
Pharmacy
Primary Care
Ment. Diabet. COPD Dement Card. CVA Cirros. KidneyH. Fail. VIH Neopl.
Primary Care Pharm. Emerg.adm. A&E Outpatient Clinics

80. ®
METHODOLOGY
Source: Programa Paciente Experto Catalunya® 2006

81. Integrated health and social care: shared approach
Empowered citizens
- selfcare
Continuity
of care
Multiple front door (mainly at
Prim. care). Unique response
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Implementation (efectiveness,
coordination, multidisciplinarity)
Monitoring, evaluation and
feedback
person-centred
Shared
information
Professional
leadership
Identification and registering (in
the community)
Community
based care
Case management
/ Shared care
Comprehensive
approach
Shared vision
& shared
outcome

82. Information System Tool for Managers in
Primary Health Care
Screen where you could monthly monitor health indicators
available for Primary Care managers