Presentation of Integrated Care

1. What is Integrated Care? 2. The ambitions of Integrated Care3. How do we work in Integrated Care?4. Milestones and actual project status

Presentation of Integrated Care

General practitioner

Common target

The citizenOwn mastery

Specialized treatment

Prevention Treatment

The municipal employee

Hospital practitioner

1. What is Integrated Care?

• A visionary partnership project • A pro-active cooperation with the citizen/patient in the centre• A systematic approach

Foundations Odense Municipality’s status as a free local authority

Local Government Denmark’s and Danish Regions’ – Close and Complete Health Services

The Government’s health political proposal North West London Integrated Care Managerial will

AND we are building on

Target group 1:

Citizens with stress, anxiety, and depression

Target group 2: The elderly medical patient

Very sick and terminalAccelerating diseaseBuilding up disease

Citizens with stress, anxiety, and depression

The elderlymedical patient

Growth-enhancing

Cost con-trolling

1 2 3 4 5 6 7 8 9 10 11 12

Real and coherent citizen-/patient process, which makes the citizen experienceto be supported by complete and proactive health care services

2. The Ambitions of Integrated Care…..

The potentials of Integrated Care

For the citizen/patient• Increased coherence and a whole process • Early tracing and efforts• Better quality of the patient treatment • Increased mastery ability• Increased function level• Improved life quality• Increased patient empowerment

For the organization • New culture• Improved co-operation methods• Altered combinatination of specialists• Changed assignment of responsibility and tasks • Common supporting tools (e.g. IT)• Other management skills

The potentials of Integrated CareFor the employee

• New holistic approach to the citizen/patient• Interdisciplinary co-operation• Cross-sectoral co-operation and relationship building• Competence development and learning• Job satisfaction

For the economy• Financially more sustainable health care services• Knowledge sharing => better basis for decision-making and prioritizing • Cost effective courses and efforts• Fewer unnecessary re-hospitalizations• Prevention of hospitalizations• Fewer citizens living on sickness benefit • Prevention of life style diseases• Increased focus on self-care

3. How do we work in Integrated Care?

Test of large-scale co-operation models (stress, anxiety, and depression/the elderly medical patient)

Proactive and common efforts rather than sectorial and late treatment (common professional fundament)

Establishment of common data warehouse Model for stratification of risk patients Description of ideal typical courses (patient programs) Committing agreements

Common task and common responsibility in cross-sectoral teams

Case conferences with the purpose of learning and adjustment Annual evaluation

The user organizations are included in the whole

process

Integrated Care samarbejdsmodellenProaktiv indsats: Fælles data og stratificering => risikopatienter findes => fælles plan udarbejdes

Forpligtende samarbejde: Fælles opgave, ansvar og udvikling i tværsektorielle og tværfaglige teams

Integrated Care – samarbejdsmodellen INGEN OVERSÆTTELSE

Illustration of the data process in Integrated CareComplementary data from the region

Complementary data from the municipality

Stratification

Regionalhealth careperson

Municipal health care person

Patient list for general practitioner

Consent before data are visible for any-body but the general practitioner

Action plan

General practitioner:Meeting with patient, agreement of data and action plan

Patient/citizen

Municipal data

Home helpNursingMedical recordRehabilitationGrant/aidsTransportationEmergency device

Municipal data

Home helpNursingMedical recordRehabilitationGrant/aidsTransportationEmergency device

Medical practice data

Diagnosis codesData from data captureNumber of medical consultations

Medical practice data

Diagnosis codesData from data captureNumber of medical consultations

Regional data

Referral to specialistsDiagnosesHospitalization frequency

Regional data

Referral to specialistsDiagnosesHospitalization frequency

Datawarehouse

Data are collected and proces-sed in data-warehouse.

Datawarehouse

Data are collected and proces-sed in data-warehouse.

Low risk

No other contemporary diagnosesGood networkGood self-care abilityStable medication

Low risk

No other contemporary diagnosesGood networkGood self-care abilityStable medication

Hig risk- Several hospitalizations- More competing illnesses- Many treating actors- Affected self-care ability- Lack of network- Bad housing conditions- Big resource requirements for local service- Cognitive deterioration

Hig risk- Several hospitalizations- More competing illnesses- Many treating actors- Affected self-care ability- Lack of network- Bad housing conditions- Big resource requirements for local service- Cognitive deterioration

Middle risk- More than one diagnosis- Frequent changes of medication- Affected self-care ability- Treatment by specialist, general practitioner and

ambulatory- High age- Fragile network

Middle risk- More than one diagnosis- Frequent changes of medication- Affected self-care ability- Treatment by specialist, general practitioner and

ambulatory- High age- Fragile network

EXAMPLE of data stratification (the elderly medical patient)

Actual project status The juridical and political foundations have been made The project organization is ready Time- and milestone schedule is followed Website: www.integratedcare.dk Common professional base (minipilot) - Common data warehouse- Stratification models version 2- Digital action plan version 1- Information material version 1- Patients included Research collaboration being established Operation date 1/9 2014 Evaluation 31st December 2015