The Journey from a Chronic Care Program toward an Integrated Health and Social Care Model Speaker: Juan Carlos Contel Segura, Department of Health, Chronic Care Program, Generalitat de Catalunya (Catalonia)

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
CATALÀ
DE LA SALUT
100%
SERVEI
CATALÀ
DE LA SALUT
100%
SUPLEMENTARY
PRIVATE
INSURERS
20%
SUPLEMENTARY
PRIVATE
INSURERS
20%
INSTITUT
CATALÀ
SALUT
(public) 20%
INSTITUT
CATALÀ
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 dispensació, unitats,
Import
Mortalitat (INE)
Data sources
Divisió d’Anàlisi de la Demanda i de l’Activitat

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 dispensació, unitats,
Import
Mortalitat (INE)
Data sources
Divisió d’Anàlisi de la Demanda i de l’Activitat

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: Nº
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 + Nº 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
“Inteligència 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,...
“Inteligència 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 Català Salut. División 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 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

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. Direcció d’Atenció Primària 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 project’s 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
doesn’t 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 Martínez
Chief Innovation Officer, TicSalut Foundation
jmartinez@ticsalut.cat

112. gencat.cat