Innovations in primary care: CASAP experience

Antoni Peris – Grao, MD

CASAP CEO

EHMA Board Member and PC SIG Chair

EFPC Advisory Board Member

VI SESSIONE Il distretto come sede di governo dei percorsi integrati e complessi

Needs and services

Citizens

Patients

Community

Population

Health

Social

MÚTUES I SERVEIS

PRIVATS

20%CENTRES PRIVATS

10%

COMPRA SERVEIS PROVISIÓ“PLA DE SALUT”

Catalan Health System

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P O P U L A T I O N

Castelldefels: 66.375EAP Can Bou: 33.089

CASAP

CUAP: 132.569

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Primary Care Teams

• Designated Geographical Coverage

• Hired according to goals and financed according to adjusted population

• Salaried Professionals

• Interdisciplinary teams

• List of assigned patients for professionals

• Scheduled consultations, spontaneous demand

• Centre, home, community

• Diagnose, treatment, follow up, promotion, prevention

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We’re not super humans…

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…we are “just” a Professional Team:PCT (8 -21h)

• 12 Family doctors

• 2 pediatricians

• 20 nurses

• 1 Social worker

• 13 clerks

• 11/2 odontologist

• 3 nurse aids

PC Emergency Unit (24h/7d):

• 2 Family doctors

• 5 nurses

• 1 nurse aid

• 2 clerks

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Professionals lists: adults

Professionals lists: adults

Professionals lists: children

Management innovation

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Team: Gateopening

P4P:

Skill-mix

Team:

Subsidiarity

Training: Skill mix

Management innovations

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Care modelinnovation

17

18

19

Care model innovation

Nurse care intervention in acute situations

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Accuracy health clerks: 90,28%

Nurses resolution: 74%

Average waiting time: 9,11 minuts

Nurse care intervention in acute situations

21

Spontaneous demand 2017

42.738

Non-scheduledconsultations

22.138 - 51,80% Family doctor

20.600 - 48,20% Nurse

16.985 - 82,45% Autonomously

3.615 - 17,55%

Family doctor consultant

Non-scheduled consultations average duration: 5 minutes

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UBA

Role

Healthy child

follow up

Acute Care

Professionals

Controls

Pediatric care innovation management

Rigid link nurse - doctor

Pediatricians: Exploration

Nurse: Health education,

techniques

Twin consultation

Exclusively pediatricians

4 pediatricians/4 nurses

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Independent selection nurse and

doctor by parents

Adapted to activity needs

3 Ped(115,36h)/ 5 nurses (156,38h)

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Nurse Managing

Two team consultation,

first and last

Nurse: relevance role

Pediatrician: consultant

Coming from Getting at

Responsiveness capacity

CUAP

Wider Service Basket

Clinical innovations

Service basket: Diagnostic Add on

Oral anticoagulant control

Blood pressure holter

Ultrasonography

Allergy studies

Non midriatic retinography and intraocular pressure

Dermatoscopy

Diagnostic management (scanner, RMN, Holter, endoscopies, treadmill test, EMG...)

Service basket: Treatment Add on

Group learning

Expert patient

Case management

Community activities

Minor surgery

Para-articular treatment

New activities

Programa COMSalut: Connectat

Pla interdepartamental d'atenció i interacció social i sanitària (PIAISS)

Pla Interdepartamental de Salut Pública (PINSAP)

E-Healthinnovation

Virtualconsultation

SMS

TICs

E-Health innovation

Creation of a Facebook profile, managed and supported by a pediatric nursing team. Theprofile is aimed at teenagers of Castelldefels, with the objective of solving and clarifyingdoubts that may arise in the easiest and most comfortable way for them.

This profile is known as 'Mar Castelldefels' and is associated with adedicated blog with content and information of interest to young people.The High Schools working on this project are: IES Les Marines, IES J. LluisSert, Sant Ferran and Escola Petit Món-Felissa Bastida.

From March 2012, 328 young people have joined, mainly from SecondaryEducation centers that belong to the Health and School program

Community health innovation

Mar Castelldefels: Salut i Escola

Model de Gestió Infermera de la Demanda ComplexaCare of patients with chronic conditions

Care for patients with complex chronic conditions

Team

Superteam intrateam

Superteam extrateam

Hospital

Issues to consider

Integrality

Patient-centeredness

Longitudinallity

Resolution

Integration / Continuity between care levels

Patients safety

Feasibility

Complex needs Nurse Management (GIDC)

• Goal: improve care of Highly complex or highly dependent patients.

• Close to PCT, identify proactively complex needs’ patients.

• Avaluate needs of patients, main carers and home/nursing home,Planning care and oferign integrated and coordinated social andHealth services.

Target population✓People with complexity and

multiple needs.

✓Comorbidity, multiple non-scheduled hospital admission orE.D. attendance in the abovementioned patients.

✓End of life situation.

✓Highly fragile elderly peopleneeding care from diverse services,including psychogeriatric units oradmission to intermediate carecenters for symptoms control.

✓Care in low prevalence processes,to foster carer empowerment ,(tracheostomy, CPAP, port-a-cat,etc).

✓People without family help or lowself care abilities.

.

FunctionsIndividualized evaluation of patient and home needs

Diagnose of problems: start and develop a coordinated intervention plan togetherwith other team professionals and mobilize resources needed.

Interventions follow up and evaluation .

Treat acute situations according to guidelines.

Inform on Health status, treatment, care and expected results both patient andfamily.

Promote self care.

Family/carer education to get as much independence as possible (awareness ofalarm signs and proceedings).

Identificació del Pacient Fràgil PCC MACA

Valoració Cuidador: Cuidador/a: Competent: Telèfon:Relació: Viu sol: Zarit:

Us segur de la medicacióMedicació: Adherència medicació: Inhaladors:

Efectes secundaris

medicació/al·lèrgies:

Efectivitat medicació: Revisar tècnica inhalador:

Valoració SocialBBAA: SPD Teleassistència:SAD públic: SAD privat: LAPAD:TS de referència: Voluntariat:

Exploració FísicaPA: FC: FR:Sat02: Edemes: P abd.:AC: AR: Pes:Tº:

Control de símptomesDolor (EVA): Nàusees/vòmits: Astènia:Signes Neurotoxicitat: Constipació: Anorèxia/hiporèxia:Malestar emocional: Ansietat/depressió: Insomni:Dispnea: NYHA:

Síndromes GeriàtricsImmobilitat: Inestabilitat i caigudes: Incontinència:Demència i SCA Desnutrició: Alteracions vista i oïda:Restrenyiment: Insomni: Iatrogènia:Immunodeficiències: Lesions cutànies: infeccions:Disfàgia: Nafres:

Valors i creencesDVA: PDA: PIIC: Religió:

AutonomiaBarthel: Lawton&Brody: Pfeiffer/ Lobo:TIRS: MNA: Yesavage:BRADEN Nº Caigudes:

Transició entre nivells/Continuïtat assistencialNº ingressos: Nº visites urgències:Risc de Descompensació: Ingrés Planificat CSS:Subaguts: Visites CUAP: SEVIAC: PADES:

Recomanacions en casa de crisis o descompensació (PIIC)Febre: Dispnea:Dolor: Alteracions consciència:Preferències del lloc on vol ser atès?

Pactat propostes d’adequació del pla terapèutic?

Pactar alguna consideració pel que fa a l’ús de tècniques o instrumentacions?

Consideració en casa de claudicació de l’entorn cuidadors o, si fos el cas, de situació d’últims

dies?

Planificació de decisions anticipades

Altra informació:

Patients with complex chronic conditionsPCC________493 | MACA______179

% Visits by ref. ________________75,41%

GIDC_______________________________40

Active pat.__________27

ICC________________11

PIIC______________40%

Passive pat.____13

NEO__________13

MPOC_________4

PCC + PIIC with recommendations___338

MACA + PIIC with recommendations_152

% PIIC _______________________84,37%

Know more about CASAP

Brugués A.B. , Peris Grao A. et al, Evaluación de la gestión enfermera de la demanda en atención primaria, Atención Primaria, 2015

Peris Grao A., Brugués A.B., Nurse gatekeeping for unscheduled patients in Primary Care, Internation Journal of Integrated Care, 2014

Brugues A., Peris A., Martí LJ., Approche des pathologies aiguës au moyen d'un Guide des Interventions Infirmières, Revue Sociologie Santé 2007; 27

Mentions on CASAP

Improving interprofessional collaboration in primary care: Position Paper of the European Forum for Primary Care

The collaboration of general practitioners and nurses in primary care: a comparative analysis of concepts and practices in Slovenia and Spain

A Better Pill to Swallow - A global view of what works in Healthcare

aperis@casap.cat

Thanks for your attention

www.casap.cat