Journey from the Chronic Condition Care Program to a New Care Model
62
A journey from the Chronic Condition Care Program to a new health and social integrated care model.
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Transcript of Journey from the Chronic Condition Care Program to a New Care Model
A journey from the Chronic Condition
Care Program to a new health and
social integrated care model
2
4 Provinces 41 Counties Districts)
947 Municipalities (64 with more than 20000 hab)
Territorial Structure of Catalonia
Source IDESCAT 2015
Ageing in Catalonia 2013-2051
In 2050
13 over 65 y
gt12 over 80y
Total population 749 million in 2013 and 795 million in2051
Elderly projection
bull gt 65 y 130 million in 2013 and 245 million in 2051
bull gt 80 y 041 million in 2013 and 094 million in 2051
bull Centenarians 1700 in 2013 and 21600 in 2051
Life expectancy at 65 years
Men 187 in 2012 and 226 in 2050 (4-year increment)
Women 227 in 2012 and 265 in 2050 (4-year increment)
Life expectancy at birth
Men 80 in 2015 and 8533 in 2050 (5-year increment)
Women 856 in 2015 and 9021 in 2050 (5-year increment)
Population projection 2013-2051
Source IDESCAT 2015
Healthcare System
bull Basic decentralization to regional autonomies
according with a basic Spanish law
bull Universal coverage
bull Free access
bull Wide range of publicly covered services
bull Services provided mainly in public facilities
bull Funded by taxes
bull Co-payment in pharmaceutical products
bull Interterritorial Board to coordinate policies 5
Social Service System
bull 100 decentralization to regional governments except for the
dependency system
bull Significant decentralization to the local
governments of the basic social services
bull Funded by taxes but with significant
Co-payment for most of the specialized
services
bull Universal coverage but not free access to the services
bull Basic social services publicly covered but specialized
services not entirely publicly covered
bull Services provided in public facilities private providers and
third sector
bull Interterritorial Board to coordinate policies
6
Catalan Healthcare System some basic features
bull Ministry of Health annual budget of 8500 million Euros
bull 369 Primary Healthcare Centres (PHC) ranging from 20-45000 inh)
bull 69 ldquoacute hospitalsrdquo (no far from 50 Km from every home)
bull 96 ldquohealth long term amp intermediate carerdquo centres (long-stay convalescence
palliative care ndash 5557 publicly funded users)
bull 41 Mental Health Centres
Catalan Social Service System some basic features
bull Ministry of Social Welfare and Family annual budget of 1500 million Euros +
extra expenditure from Local authorities
bull 106 Basic social services Areas run by local governments (min 20000 inh)
bull 48173 publicly funded users for residential care (including residential homes
supervised housing and health long term care for elderly disability mental health
and children)
bull 19287 publicly funded users for daily care
7
Different maps of service delivery areas
Chronic Condition Care Program
2011
1
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
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 oriented towards chronic patients
3 A more responsive system from the first levels
4 System with better quality in high-level specialties
The Catalan Health Plan 2011 - 2015
21 Integrated clinical processes
22 Protection promotion and prevention
23 Co-responsibility and self-care
24 Alternatives in an integrated system
25 Complex chronic patients
26 Rational prescription and use of drugs
Strategic lines Chronic Condition Care Program
All
str
ate
gic
lin
es r
equire I
CT
tools
and d
evelo
pm
ents
Documents
published per
year
23097493
bull 2119605 Average documents published per month
bull 92262770 Indexed documents
bull 6704591 Patients with reports
Shared Clinical Record (HC3)
PCC Multimorbidity
Severe unique
disease
Advanced frailty
MACA Limited live
prognosis Palliative
approach Advance
care planning
12
Labeling two profiles of complexity
-Care centres that have patients
classified and marked in these two
types can publish this labelmark in
HC3
- The classification label must be
visible on all the screens given the
importance of the condition
PCC Complex Chronic Patient
MACA Advanced chronic
disease
9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target
25000 complex
chronic patients
should be identified by
2015
In January 2015 over
120000 patients
included
Evolution in number of PCC and MACA
ldquoLabelingrdquo available since January 2013
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
2
4 Provinces 41 Counties Districts)
947 Municipalities (64 with more than 20000 hab)
Territorial Structure of Catalonia
Source IDESCAT 2015
Ageing in Catalonia 2013-2051
In 2050
13 over 65 y
gt12 over 80y
Total population 749 million in 2013 and 795 million in2051
Elderly projection
bull gt 65 y 130 million in 2013 and 245 million in 2051
bull gt 80 y 041 million in 2013 and 094 million in 2051
bull Centenarians 1700 in 2013 and 21600 in 2051
Life expectancy at 65 years
Men 187 in 2012 and 226 in 2050 (4-year increment)
Women 227 in 2012 and 265 in 2050 (4-year increment)
Life expectancy at birth
Men 80 in 2015 and 8533 in 2050 (5-year increment)
Women 856 in 2015 and 9021 in 2050 (5-year increment)
Population projection 2013-2051
Source IDESCAT 2015
Healthcare System
bull Basic decentralization to regional autonomies
according with a basic Spanish law
bull Universal coverage
bull Free access
bull Wide range of publicly covered services
bull Services provided mainly in public facilities
bull Funded by taxes
bull Co-payment in pharmaceutical products
bull Interterritorial Board to coordinate policies 5
Social Service System
bull 100 decentralization to regional governments except for the
dependency system
bull Significant decentralization to the local
governments of the basic social services
bull Funded by taxes but with significant
Co-payment for most of the specialized
services
bull Universal coverage but not free access to the services
bull Basic social services publicly covered but specialized
services not entirely publicly covered
bull Services provided in public facilities private providers and
third sector
bull Interterritorial Board to coordinate policies
6
Catalan Healthcare System some basic features
bull Ministry of Health annual budget of 8500 million Euros
bull 369 Primary Healthcare Centres (PHC) ranging from 20-45000 inh)
bull 69 ldquoacute hospitalsrdquo (no far from 50 Km from every home)
bull 96 ldquohealth long term amp intermediate carerdquo centres (long-stay convalescence
palliative care ndash 5557 publicly funded users)
bull 41 Mental Health Centres
Catalan Social Service System some basic features
bull Ministry of Social Welfare and Family annual budget of 1500 million Euros +
extra expenditure from Local authorities
bull 106 Basic social services Areas run by local governments (min 20000 inh)
bull 48173 publicly funded users for residential care (including residential homes
supervised housing and health long term care for elderly disability mental health
and children)
bull 19287 publicly funded users for daily care
7
Different maps of service delivery areas
Chronic Condition Care Program
2011
1
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
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 oriented towards chronic patients
3 A more responsive system from the first levels
4 System with better quality in high-level specialties
The Catalan Health Plan 2011 - 2015
21 Integrated clinical processes
22 Protection promotion and prevention
23 Co-responsibility and self-care
24 Alternatives in an integrated system
25 Complex chronic patients
26 Rational prescription and use of drugs
Strategic lines Chronic Condition Care Program
All
str
ate
gic
lin
es r
equire I
CT
tools
and d
evelo
pm
ents
Documents
published per
year
23097493
bull 2119605 Average documents published per month
bull 92262770 Indexed documents
bull 6704591 Patients with reports
Shared Clinical Record (HC3)
PCC Multimorbidity
Severe unique
disease
Advanced frailty
MACA Limited live
prognosis Palliative
approach Advance
care planning
12
Labeling two profiles of complexity
-Care centres that have patients
classified and marked in these two
types can publish this labelmark in
HC3
- The classification label must be
visible on all the screens given the
importance of the condition
PCC Complex Chronic Patient
MACA Advanced chronic
disease
9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target
25000 complex
chronic patients
should be identified by
2015
In January 2015 over
120000 patients
included
Evolution in number of PCC and MACA
ldquoLabelingrdquo available since January 2013
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Source IDESCAT 2015
Ageing in Catalonia 2013-2051
In 2050
13 over 65 y
gt12 over 80y
Total population 749 million in 2013 and 795 million in2051
Elderly projection
bull gt 65 y 130 million in 2013 and 245 million in 2051
bull gt 80 y 041 million in 2013 and 094 million in 2051
bull Centenarians 1700 in 2013 and 21600 in 2051
Life expectancy at 65 years
Men 187 in 2012 and 226 in 2050 (4-year increment)
Women 227 in 2012 and 265 in 2050 (4-year increment)
Life expectancy at birth
Men 80 in 2015 and 8533 in 2050 (5-year increment)
Women 856 in 2015 and 9021 in 2050 (5-year increment)
Population projection 2013-2051
Source IDESCAT 2015
Healthcare System
bull Basic decentralization to regional autonomies
according with a basic Spanish law
bull Universal coverage
bull Free access
bull Wide range of publicly covered services
bull Services provided mainly in public facilities
bull Funded by taxes
bull Co-payment in pharmaceutical products
bull Interterritorial Board to coordinate policies 5
Social Service System
bull 100 decentralization to regional governments except for the
dependency system
bull Significant decentralization to the local
governments of the basic social services
bull Funded by taxes but with significant
Co-payment for most of the specialized
services
bull Universal coverage but not free access to the services
bull Basic social services publicly covered but specialized
services not entirely publicly covered
bull Services provided in public facilities private providers and
third sector
bull Interterritorial Board to coordinate policies
6
Catalan Healthcare System some basic features
bull Ministry of Health annual budget of 8500 million Euros
bull 369 Primary Healthcare Centres (PHC) ranging from 20-45000 inh)
bull 69 ldquoacute hospitalsrdquo (no far from 50 Km from every home)
bull 96 ldquohealth long term amp intermediate carerdquo centres (long-stay convalescence
palliative care ndash 5557 publicly funded users)
bull 41 Mental Health Centres
Catalan Social Service System some basic features
bull Ministry of Social Welfare and Family annual budget of 1500 million Euros +
extra expenditure from Local authorities
bull 106 Basic social services Areas run by local governments (min 20000 inh)
bull 48173 publicly funded users for residential care (including residential homes
supervised housing and health long term care for elderly disability mental health
and children)
bull 19287 publicly funded users for daily care
7
Different maps of service delivery areas
Chronic Condition Care Program
2011
1
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
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 oriented towards chronic patients
3 A more responsive system from the first levels
4 System with better quality in high-level specialties
The Catalan Health Plan 2011 - 2015
21 Integrated clinical processes
22 Protection promotion and prevention
23 Co-responsibility and self-care
24 Alternatives in an integrated system
25 Complex chronic patients
26 Rational prescription and use of drugs
Strategic lines Chronic Condition Care Program
All
str
ate
gic
lin
es r
equire I
CT
tools
and d
evelo
pm
ents
Documents
published per
year
23097493
bull 2119605 Average documents published per month
bull 92262770 Indexed documents
bull 6704591 Patients with reports
Shared Clinical Record (HC3)
PCC Multimorbidity
Severe unique
disease
Advanced frailty
MACA Limited live
prognosis Palliative
approach Advance
care planning
12
Labeling two profiles of complexity
-Care centres that have patients
classified and marked in these two
types can publish this labelmark in
HC3
- The classification label must be
visible on all the screens given the
importance of the condition
PCC Complex Chronic Patient
MACA Advanced chronic
disease
9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target
25000 complex
chronic patients
should be identified by
2015
In January 2015 over
120000 patients
included
Evolution in number of PCC and MACA
ldquoLabelingrdquo available since January 2013
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Total population 749 million in 2013 and 795 million in2051
Elderly projection
bull gt 65 y 130 million in 2013 and 245 million in 2051
bull gt 80 y 041 million in 2013 and 094 million in 2051
bull Centenarians 1700 in 2013 and 21600 in 2051
Life expectancy at 65 years
Men 187 in 2012 and 226 in 2050 (4-year increment)
Women 227 in 2012 and 265 in 2050 (4-year increment)
Life expectancy at birth
Men 80 in 2015 and 8533 in 2050 (5-year increment)
Women 856 in 2015 and 9021 in 2050 (5-year increment)
Population projection 2013-2051
Source IDESCAT 2015
Healthcare System
bull Basic decentralization to regional autonomies
according with a basic Spanish law
bull Universal coverage
bull Free access
bull Wide range of publicly covered services
bull Services provided mainly in public facilities
bull Funded by taxes
bull Co-payment in pharmaceutical products
bull Interterritorial Board to coordinate policies 5
Social Service System
bull 100 decentralization to regional governments except for the
dependency system
bull Significant decentralization to the local
governments of the basic social services
bull Funded by taxes but with significant
Co-payment for most of the specialized
services
bull Universal coverage but not free access to the services
bull Basic social services publicly covered but specialized
services not entirely publicly covered
bull Services provided in public facilities private providers and
third sector
bull Interterritorial Board to coordinate policies
6
Catalan Healthcare System some basic features
bull Ministry of Health annual budget of 8500 million Euros
bull 369 Primary Healthcare Centres (PHC) ranging from 20-45000 inh)
bull 69 ldquoacute hospitalsrdquo (no far from 50 Km from every home)
bull 96 ldquohealth long term amp intermediate carerdquo centres (long-stay convalescence
palliative care ndash 5557 publicly funded users)
bull 41 Mental Health Centres
Catalan Social Service System some basic features
bull Ministry of Social Welfare and Family annual budget of 1500 million Euros +
extra expenditure from Local authorities
bull 106 Basic social services Areas run by local governments (min 20000 inh)
bull 48173 publicly funded users for residential care (including residential homes
supervised housing and health long term care for elderly disability mental health
and children)
bull 19287 publicly funded users for daily care
7
Different maps of service delivery areas
Chronic Condition Care Program
2011
1
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
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 oriented towards chronic patients
3 A more responsive system from the first levels
4 System with better quality in high-level specialties
The Catalan Health Plan 2011 - 2015
21 Integrated clinical processes
22 Protection promotion and prevention
23 Co-responsibility and self-care
24 Alternatives in an integrated system
25 Complex chronic patients
26 Rational prescription and use of drugs
Strategic lines Chronic Condition Care Program
All
str
ate
gic
lin
es r
equire I
CT
tools
and d
evelo
pm
ents
Documents
published per
year
23097493
bull 2119605 Average documents published per month
bull 92262770 Indexed documents
bull 6704591 Patients with reports
Shared Clinical Record (HC3)
PCC Multimorbidity
Severe unique
disease
Advanced frailty
MACA Limited live
prognosis Palliative
approach Advance
care planning
12
Labeling two profiles of complexity
-Care centres that have patients
classified and marked in these two
types can publish this labelmark in
HC3
- The classification label must be
visible on all the screens given the
importance of the condition
PCC Complex Chronic Patient
MACA Advanced chronic
disease
9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target
25000 complex
chronic patients
should be identified by
2015
In January 2015 over
120000 patients
included
Evolution in number of PCC and MACA
ldquoLabelingrdquo available since January 2013
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Healthcare System
bull Basic decentralization to regional autonomies
according with a basic Spanish law
bull Universal coverage
bull Free access
bull Wide range of publicly covered services
bull Services provided mainly in public facilities
bull Funded by taxes
bull Co-payment in pharmaceutical products
bull Interterritorial Board to coordinate policies 5
Social Service System
bull 100 decentralization to regional governments except for the
dependency system
bull Significant decentralization to the local
governments of the basic social services
bull Funded by taxes but with significant
Co-payment for most of the specialized
services
bull Universal coverage but not free access to the services
bull Basic social services publicly covered but specialized
services not entirely publicly covered
bull Services provided in public facilities private providers and
third sector
bull Interterritorial Board to coordinate policies
6
Catalan Healthcare System some basic features
bull Ministry of Health annual budget of 8500 million Euros
bull 369 Primary Healthcare Centres (PHC) ranging from 20-45000 inh)
bull 69 ldquoacute hospitalsrdquo (no far from 50 Km from every home)
bull 96 ldquohealth long term amp intermediate carerdquo centres (long-stay convalescence
palliative care ndash 5557 publicly funded users)
bull 41 Mental Health Centres
Catalan Social Service System some basic features
bull Ministry of Social Welfare and Family annual budget of 1500 million Euros +
extra expenditure from Local authorities
bull 106 Basic social services Areas run by local governments (min 20000 inh)
bull 48173 publicly funded users for residential care (including residential homes
supervised housing and health long term care for elderly disability mental health
and children)
bull 19287 publicly funded users for daily care
7
Different maps of service delivery areas
Chronic Condition Care Program
2011
1
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
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 oriented towards chronic patients
3 A more responsive system from the first levels
4 System with better quality in high-level specialties
The Catalan Health Plan 2011 - 2015
21 Integrated clinical processes
22 Protection promotion and prevention
23 Co-responsibility and self-care
24 Alternatives in an integrated system
25 Complex chronic patients
26 Rational prescription and use of drugs
Strategic lines Chronic Condition Care Program
All
str
ate
gic
lin
es r
equire I
CT
tools
and d
evelo
pm
ents
Documents
published per
year
23097493
bull 2119605 Average documents published per month
bull 92262770 Indexed documents
bull 6704591 Patients with reports
Shared Clinical Record (HC3)
PCC Multimorbidity
Severe unique
disease
Advanced frailty
MACA Limited live
prognosis Palliative
approach Advance
care planning
12
Labeling two profiles of complexity
-Care centres that have patients
classified and marked in these two
types can publish this labelmark in
HC3
- The classification label must be
visible on all the screens given the
importance of the condition
PCC Complex Chronic Patient
MACA Advanced chronic
disease
9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target
25000 complex
chronic patients
should be identified by
2015
In January 2015 over
120000 patients
included
Evolution in number of PCC and MACA
ldquoLabelingrdquo available since January 2013
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Social Service System
bull 100 decentralization to regional governments except for the
dependency system
bull Significant decentralization to the local
governments of the basic social services
bull Funded by taxes but with significant
Co-payment for most of the specialized
services
bull Universal coverage but not free access to the services
bull Basic social services publicly covered but specialized
services not entirely publicly covered
bull Services provided in public facilities private providers and
third sector
bull Interterritorial Board to coordinate policies
6
Catalan Healthcare System some basic features
bull Ministry of Health annual budget of 8500 million Euros
bull 369 Primary Healthcare Centres (PHC) ranging from 20-45000 inh)
bull 69 ldquoacute hospitalsrdquo (no far from 50 Km from every home)
bull 96 ldquohealth long term amp intermediate carerdquo centres (long-stay convalescence
palliative care ndash 5557 publicly funded users)
bull 41 Mental Health Centres
Catalan Social Service System some basic features
bull Ministry of Social Welfare and Family annual budget of 1500 million Euros +
extra expenditure from Local authorities
bull 106 Basic social services Areas run by local governments (min 20000 inh)
bull 48173 publicly funded users for residential care (including residential homes
supervised housing and health long term care for elderly disability mental health
and children)
bull 19287 publicly funded users for daily care
7
Different maps of service delivery areas
Chronic Condition Care Program
2011
1
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
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 oriented towards chronic patients
3 A more responsive system from the first levels
4 System with better quality in high-level specialties
The Catalan Health Plan 2011 - 2015
21 Integrated clinical processes
22 Protection promotion and prevention
23 Co-responsibility and self-care
24 Alternatives in an integrated system
25 Complex chronic patients
26 Rational prescription and use of drugs
Strategic lines Chronic Condition Care Program
All
str
ate
gic
lin
es r
equire I
CT
tools
and d
evelo
pm
ents
Documents
published per
year
23097493
bull 2119605 Average documents published per month
bull 92262770 Indexed documents
bull 6704591 Patients with reports
Shared Clinical Record (HC3)
PCC Multimorbidity
Severe unique
disease
Advanced frailty
MACA Limited live
prognosis Palliative
approach Advance
care planning
12
Labeling two profiles of complexity
-Care centres that have patients
classified and marked in these two
types can publish this labelmark in
HC3
- The classification label must be
visible on all the screens given the
importance of the condition
PCC Complex Chronic Patient
MACA Advanced chronic
disease
9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target
25000 complex
chronic patients
should be identified by
2015
In January 2015 over
120000 patients
included
Evolution in number of PCC and MACA
ldquoLabelingrdquo available since January 2013
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Catalan Healthcare System some basic features
bull Ministry of Health annual budget of 8500 million Euros
bull 369 Primary Healthcare Centres (PHC) ranging from 20-45000 inh)
bull 69 ldquoacute hospitalsrdquo (no far from 50 Km from every home)
bull 96 ldquohealth long term amp intermediate carerdquo centres (long-stay convalescence
palliative care ndash 5557 publicly funded users)
bull 41 Mental Health Centres
Catalan Social Service System some basic features
bull Ministry of Social Welfare and Family annual budget of 1500 million Euros +
extra expenditure from Local authorities
bull 106 Basic social services Areas run by local governments (min 20000 inh)
bull 48173 publicly funded users for residential care (including residential homes
supervised housing and health long term care for elderly disability mental health
and children)
bull 19287 publicly funded users for daily care
7
Different maps of service delivery areas
Chronic Condition Care Program
2011
1
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
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 oriented towards chronic patients
3 A more responsive system from the first levels
4 System with better quality in high-level specialties
The Catalan Health Plan 2011 - 2015
21 Integrated clinical processes
22 Protection promotion and prevention
23 Co-responsibility and self-care
24 Alternatives in an integrated system
25 Complex chronic patients
26 Rational prescription and use of drugs
Strategic lines Chronic Condition Care Program
All
str
ate
gic
lin
es r
equire I
CT
tools
and d
evelo
pm
ents
Documents
published per
year
23097493
bull 2119605 Average documents published per month
bull 92262770 Indexed documents
bull 6704591 Patients with reports
Shared Clinical Record (HC3)
PCC Multimorbidity
Severe unique
disease
Advanced frailty
MACA Limited live
prognosis Palliative
approach Advance
care planning
12
Labeling two profiles of complexity
-Care centres that have patients
classified and marked in these two
types can publish this labelmark in
HC3
- The classification label must be
visible on all the screens given the
importance of the condition
PCC Complex Chronic Patient
MACA Advanced chronic
disease
9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target
25000 complex
chronic patients
should be identified by
2015
In January 2015 over
120000 patients
included
Evolution in number of PCC and MACA
ldquoLabelingrdquo available since January 2013
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Chronic Condition Care Program
2011
1
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
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 oriented towards chronic patients
3 A more responsive system from the first levels
4 System with better quality in high-level specialties
The Catalan Health Plan 2011 - 2015
21 Integrated clinical processes
22 Protection promotion and prevention
23 Co-responsibility and self-care
24 Alternatives in an integrated system
25 Complex chronic patients
26 Rational prescription and use of drugs
Strategic lines Chronic Condition Care Program
All
str
ate
gic
lin
es r
equire I
CT
tools
and d
evelo
pm
ents
Documents
published per
year
23097493
bull 2119605 Average documents published per month
bull 92262770 Indexed documents
bull 6704591 Patients with reports
Shared Clinical Record (HC3)
PCC Multimorbidity
Severe unique
disease
Advanced frailty
MACA Limited live
prognosis Palliative
approach Advance
care planning
12
Labeling two profiles of complexity
-Care centres that have patients
classified and marked in these two
types can publish this labelmark in
HC3
- The classification label must be
visible on all the screens given the
importance of the condition
PCC Complex Chronic Patient
MACA Advanced chronic
disease
9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target
25000 complex
chronic patients
should be identified by
2015
In January 2015 over
120000 patients
included
Evolution in number of PCC and MACA
ldquoLabelingrdquo available since January 2013
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
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
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 oriented towards chronic patients
3 A more responsive system from the first levels
4 System with better quality in high-level specialties
The Catalan Health Plan 2011 - 2015
21 Integrated clinical processes
22 Protection promotion and prevention
23 Co-responsibility and self-care
24 Alternatives in an integrated system
25 Complex chronic patients
26 Rational prescription and use of drugs
Strategic lines Chronic Condition Care Program
All
str
ate
gic
lin
es r
equire I
CT
tools
and d
evelo
pm
ents
Documents
published per
year
23097493
bull 2119605 Average documents published per month
bull 92262770 Indexed documents
bull 6704591 Patients with reports
Shared Clinical Record (HC3)
PCC Multimorbidity
Severe unique
disease
Advanced frailty
MACA Limited live
prognosis Palliative
approach Advance
care planning
12
Labeling two profiles of complexity
-Care centres that have patients
classified and marked in these two
types can publish this labelmark in
HC3
- The classification label must be
visible on all the screens given the
importance of the condition
PCC Complex Chronic Patient
MACA Advanced chronic
disease
9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target
25000 complex
chronic patients
should be identified by
2015
In January 2015 over
120000 patients
included
Evolution in number of PCC and MACA
ldquoLabelingrdquo available since January 2013
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
21 Integrated clinical processes
22 Protection promotion and prevention
23 Co-responsibility and self-care
24 Alternatives in an integrated system
25 Complex chronic patients
26 Rational prescription and use of drugs
Strategic lines Chronic Condition Care Program
All
str
ate
gic
lin
es r
equire I
CT
tools
and d
evelo
pm
ents
Documents
published per
year
23097493
bull 2119605 Average documents published per month
bull 92262770 Indexed documents
bull 6704591 Patients with reports
Shared Clinical Record (HC3)
PCC Multimorbidity
Severe unique
disease
Advanced frailty
MACA Limited live
prognosis Palliative
approach Advance
care planning
12
Labeling two profiles of complexity
-Care centres that have patients
classified and marked in these two
types can publish this labelmark in
HC3
- The classification label must be
visible on all the screens given the
importance of the condition
PCC Complex Chronic Patient
MACA Advanced chronic
disease
9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target
25000 complex
chronic patients
should be identified by
2015
In January 2015 over
120000 patients
included
Evolution in number of PCC and MACA
ldquoLabelingrdquo available since January 2013
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Documents
published per
year
23097493
bull 2119605 Average documents published per month
bull 92262770 Indexed documents
bull 6704591 Patients with reports
Shared Clinical Record (HC3)
PCC Multimorbidity
Severe unique
disease
Advanced frailty
MACA Limited live
prognosis Palliative
approach Advance
care planning
12
Labeling two profiles of complexity
-Care centres that have patients
classified and marked in these two
types can publish this labelmark in
HC3
- The classification label must be
visible on all the screens given the
importance of the condition
PCC Complex Chronic Patient
MACA Advanced chronic
disease
9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target
25000 complex
chronic patients
should be identified by
2015
In January 2015 over
120000 patients
included
Evolution in number of PCC and MACA
ldquoLabelingrdquo available since January 2013
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
PCC Multimorbidity
Severe unique
disease
Advanced frailty
MACA Limited live
prognosis Palliative
approach Advance
care planning
12
Labeling two profiles of complexity
-Care centres that have patients
classified and marked in these two
types can publish this labelmark in
HC3
- The classification label must be
visible on all the screens given the
importance of the condition
PCC Complex Chronic Patient
MACA Advanced chronic
disease
9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target
25000 complex
chronic patients
should be identified by
2015
In January 2015 over
120000 patients
included
Evolution in number of PCC and MACA
ldquoLabelingrdquo available since January 2013
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
9980
1765
11745
64117
12300
76440
92000
28000
120000
0
20000
40000
60000
80000
100000
120000
140000
PCC MACA TOTAL
April 2013 Dec 2013 Dec 2014
Initial Health Plan
target
25000 complex
chronic patients
should be identified by
2015
In January 2015 over
120000 patients
included
Evolution in number of PCC and MACA
ldquoLabelingrdquo available since January 2013
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Guarantying a basic health assessment in Complex Chronic Patients
bull Basic standardized and customized assessment Functional + Cognitive
impairment + Social Risk + Depression
bull NECPAL assessment to identify ldquoAdvanced Chronic Diseaserdquo condition
bull Complementary assessment
Challenge
To construct a shared and
joint Assessment and
Intervention Plan
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Health problemsDiagnosis
Active Medication
Allergies
Recommendations for ldquoin case of
crisisrdquo or exacerbation
Advanced Care Planning
Resources and services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
WARNINGS and ALERTS
Discharge Planning
Challenge
To incorporate new
hospitals beyond ICS and
long term care facilities
guaranteeing ldquoTransional
carerdquo with Primary Health
Care and Social Services (in
short time)
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Defining a stratification model Population based
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
17
Visualizing in Shared Clinical Record and different RISK scores
Stratification and Emergency admission risk
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
CMBS (minimum data set) unified data base data sources
Insured data source NIA demographic data
Diagnosis data base
NIA tipus_codi codi data dx UP tipus_UP
ldquoContactrdquo data base
NIA dates contacte UP tipus_UP urgent CatSalut T_act
MDS-Hospital
MDS-PHC
MDS-MH
MDS-NH
MDS-AampE
Central Registered Insured
Health Problems
Pharmacy (PHC and hospital
provided)
Pharmacy data base
NIA ATC data dispensacioacute unitats Import
Mortalitat (INE)
Divisioacute drsquoAnagravelisi de la Demanda i de lrsquoActivitat 18
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Clinical Risk Groups and levels of aggregation Standard aggregation 1000 groups (CRG) Aggregation in groups
St 9 High need
condition
St 8 Severe neopl
St 7 Chronic cond 3
or more organs
St 6 Chronic cond
2 organs
St 5 Chronic condit
St 4 Minor chronic
cond diff organs
St 3 Minor chronic
cond
St 2 Acute condition
St 1 Healthy
History of Heart
Transplant
Metastatic Colon
Malignancy
Heart Failure +
Diabetes + COPD
HF + Diabetes
Diabetes
Migraine+
Hiperlipidemia
Migraine
Pneumonia
Healthy
1 4
1 4
1 6
1 6
1 4
1 4
1 2
Health Status CRG Basic Severity
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
Healt
h S
tatu
s
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 1000 groups Too
much
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
New ldquopanel managementrdquo introduced
bullIt has been converted information
into warnings when we access to
clinical record in each visit
bullCustomized configuration per
professional and team
bullWarnings sorted by importance and
relevance
bullWeekly calculation
bullldquoFront-officerdquo and ldquoback officerdquo
modality
Mean 20-30 improvement in some scores
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Multimorbidity in Catalonia obtained by stratification
Challenge
It is required to
include
ldquosocial datardquo
to adjust
stratification
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Prevalence of multimorbidity Information available at regional and PHC level
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
1 18 133 10992euro 13 13
2 7 57 5872euro 13 26
8 3 28 3162euro 28 54
17 1 14 1411euro 25 79
72 0 2 282euro 21 100
POPULATION MORTALITY TAX
HOSPITALI-ZATION TAX
ESTIMATED EXPENSE
ACCUMU-LATED
Impact distribution of different segments
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Who are the PCC and MACA patients
Source CatSalut 2013
PCC MACA
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
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
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Defining shared indicators
Indicators Primary
Care
Hospital
Care
intermediate
care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes good control
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease (COPD)
and Heart Failure (HF)
++ +++ +
COPDHF Avoidable Hospital
Admission
++ ++
Discharge planning in ldquoPRE-
Dischargerdquo program
++ - -
To ensure continuity care in ldquoPOST-
Dischargerdquo program
- ++ ++
ldquoQuality of liferdquo (HRQoL) assessment ++ ++ ++ Challenge
To aggregate health and social
care data
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Expert assessment quality measure related to Chronic Care
final selection of 25-30 indicators
Importancerelevance for management
Importancerelevance for clinicians
Importancerelevance for citizens
Feasibility data available
Generating ldquoclinical integrationrdquo
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
bull Indicators of admissions for every Sector and Primary Health Team bull 14 chronic diseases bull Benchmarking with different standards among PHT and Hospitals
Servei Catalagrave Salut Divisioacuten de Registros
Using quality measures MSIQ
MSIQ http1462192561msiqindexhtml
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Hospital admission by diagnostic groups gt 70 y
0 4000 8000 12000 16000
Hipertensioacute essencial
Deliri demegravencia i altres trastorns cognitius i amnegravesics
Trastorns del metabolisme hidroelectroliacutetic
Asma
Infeccions i ulcera crogravenica pell
Diabetis mellitus amb complicacions
Hipertensioacute amb complicacions i hipertensioacute secundagraveria
Pneumogravenia per aspiracioacute daliments o vogravemits
Infeccions de vies urinagraveries
Pneumogravenia (excloent-ne per tuberculosi i MTS)
Malaltia pulmonar obstructiva crogravenica i bronquiegravectasi
Insuficiegravencia cardiacuteaca congestiva
70 and more
Pneumonia
Source DGPRS Dep Salut 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Large differences in emergency hospital admission rates by
sector (x 100000 inhab)
400
600
800
1000
1200
1400
1600
1800
Catalan average 971 x 100000 inh
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Large differences in readmission rates by sector
4
6
8
10
12
14
16
Catalan average 1078
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Hospital admissions for chronic conditions
Monthly udpated information
Includes COPD HF DM complications asthma coronary diseases HTA
Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
minus8 last 24 months
7096
6841
6527
620
630
640
650
660
670
680
690
700
710
720
2011 2012 2013
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Potentially avoidable hospital admissions for COPD
Decrease by 131 from Dec 2011 to Dec 2013 (24 months)
Availability of evolution of avoidable emergency admissions per region sector PHC team (x 100000 inhab Tax)
Source MSIQ Catsalut
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
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 100000 inhab Tax)
trend Increase by 25
from 2006 till 2011
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Emergency admissions related to COPD exacerbation
More than a half
emergency
admissions
compared to
Catalan average
(x 100000 inhab)
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
More than a half
emergency
admissions compared
to Catalan average
(adjusted data)
Emergency admissions related to COPD exacerbation
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Variability Atlas related to indicators
SourceEvaluation and Quality Agency
Population based related to
Primary care area
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Implementing integrated care pathways (within the health system)
bull Integrated Care Pathways as a formal agreement among professional clinical leaders
at local level
bull Based on reference clinical guidelines and best evidence practice
bull 80 of territories implemented 3 of 4 chronic conditions COPD depression heart
failure and DM2 Now Complex Cronic Care Pathways work
bull Agreement on different ldquosituationsrdquo 0 Diagnosis 1 Stable 2 Acute exacerbation 3
Management difficulty 4 Transitional Care Other 6 conditions to be included in the future
8 pilot projects on health and social integrated care
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Check list for support of deployment complexity care model
Basic and Priority ldquoPCCrdquo and ldquoMACArdquo identification and
labelling + Integrated Care Pathway + 24 7 model +
Carer identification and support
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Changing the contract 2013 with common PHC-Hospital Targets
40
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 (ldquoTERRITORYrdquo) (20)
minimum PCCMACA with Intervention Plan (ldquoPIICrdquo)
minimum PCCMACA with medication review
minimum PCCMACA with post-discharge medication conciliation
Reduction emergency admissions in PCCMACA
Minimum number participants Expert Patient Program
minimum COPD patients with spirometry
minimum PHC with Mental Health integration
Prevalence minimum depresion with ldquoseverityrdquo criteria
minimum patients with depresion with ldquosuicide riskrdquo assessment
Development at local level a consultant virtual office
ldquoAmputation raterdquo reduction in DM
ldquoOphthalmologylocomotor ldquo referral first visits under expected tax
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
41
Labeling two profiles of complexity
Guarantying a basic health assessment in Complex Chronic Patients
Ensuring a ldquoHealth shared Individual Intervention Planrdquo for all pcc
Defining a stratification model Population based
Visualizing in Shared Clinical Record and different RISK scores
Defining shared indicators
Using quality measures MSIQ
Implementing integrated care pathways (within the health system)
Changing the contract 2013 with common PHC-Hospital Targets
8 pilot projects on health and social integrated care
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
42
2014 A step forward to a model of health and social
integrated care
2
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
3 September 2013
Government Agreement where is expected
to develop a new Integrated Health and
Social Care Plan in Catalonia
3 December 2013
New IT shared health and social care
record is expected to shared in the next
time
25 February 2014
New Government Agreement for the
creation of the PIAISS
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Inter-ministerial Social and Health Care and Interaction Plan
44
Mission Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated people-based care that responds to their needs
Promoted by the Government of Catalonia with the participation of
the Presidential Ministry the Ministry of Social Welfare and
Family and the Ministry of Health
The aim is to catalyze necessary actions to accomplish an
integrated system that guarantees social and health care to
people who have health and social complex care needs
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Contribute to maintain the level of health and social welfare results
outcomes for the target population
Improve perception of quality on the experience of care to the health
and social needs for the target population
Contribute to the sustainability of the current welfare system
guaranteeing the best use of resources
Guarantee a planed proactive personalized co-ordinated and
adapted to the individual health and social care needs improving the
quality of care and increasing the co-responsability and empowerment
of the person
Integrated care why
45
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Integrated Care for who
Population based
Existing concurrent health and social care needs
Present complex condition or at risk of
PCC Multimorbidity
Severe unique disease Advanced frailty
MACA Limited live prognosis Palliative approach
Advance care planning
Functional autonomy needs
Interpersonal and relational needs
Instrumental and material needs
Healthcare complex needs Social care complex needs
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
For us complexity has to do with
50
RELATED WITH MORBIDITY
UNCERTANLY It is difficult to predict what is the best decision
MULTIMORBIDITY accumulation of problems you have to manage and decide about
INSTABILITY The difficulty of finding an equilibrium state
GRAVITY Intensity that the problem is manifested
PROGRESSION Speed with which the situation can deteriorate
RELATED WITH THE PROFESSIONALS
MULTIPLICITY many actors involved in the decision making
LACK OF AGREEMENT experts may not agree on the recommendation
RELATED WITH THE PERSON
FRAILTY Low personal resilience
IMBALANCE From an area that can decompensate other
ANOSOGNOSIS lack of awareness of the problem
NO VOLITION lowzero collaborative attitude about the need of change despite this awareness
QUALITY OF THE NETWORK relational community family support
RELATED WITH THE SYSTEM
FRAGMENTATION professional organizations and services fragmented
NO ABAILABILITY OF THE INDICATED RESOURCE
Font Elaboracioacute progravepia del PPAC i PIAISS Blay C Ledesma A Contel JC Gonzaacutelez C Sarquella E Viguera Ll I aportacions de Varea JA
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Integrated health and social care shared approach
Multiple front door (mainly at Prim
care) Unique response
Implementation (efectiveness
coordination multidisciplinarity)
Join and comprehensive
assessment for health and social
needs
Shared proactive action Plan
Monitoring evaluation and
feedback
Identification and registering (in the
community)
Case m
an
ag
em
en
t
Sh
are
d c
are
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Catalan Model of Health and Social Integrated Care Core amp enabling elements
ldquoMicrosystemsrdquo bull Community-based and
primary care leadership bull Integrated care pathways bull Multiprofessional work bull Transitional care bull Out of hours care bull Home care strategies
Joint case care load Shared needs assessment + action plan
Stratification models assessing population needs
Clinical and professional leadership
Health and social care local Partnerships
Shared outcome framework shared responsibility amp joined accountability
Shared vision about the use of resources Aligned Incentives
Shared Electronic Health and Social record
Person Empowerment and Self-care
ENABLING ELEMENTS
Multi-lever approach ALL things at the same time
Culture and change management
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Build Plane In The Air httpyoutubeM3hge6Bx-4w
Projects and actions
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Font Elaboracioacute progravepia del PPAC i PIAISS i PDS
Catalan model of care for people who
lives in residential facilities Integrated care in mental health and
addictions network
Catalan Model for home care (health
and social home care amp telecare)
Changing the role of the citizens in this
new model of care
Health and Social Care ICT Integration
Consensus i leadership with and
from the sectors Advice committee
Participation committee
2nd level of advice committee
Terminological consensus
Standards and catalogues
definition on social data
Shared outcomes
framework definition
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Hospitals
Integrated Care more than multi-level health care integration
wwwflaticoncom (1) wwwfreepikcom (1) (2) wwwmorguefilecom
COMMUNITY
HEALTH AND SOCIAL PRIMARY CARE SERVICES
Emergency service
Paliative care
Long term care
Intermediate care
Residential care
Nursing homes
Daily care
Home care
Project 4 Local partnerships implementation
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
57
Reus
Lleida
Salt ndash Gironegraves
Alt Penedegraves Vilafranca i comarca
Mataroacute
Vilanova i la Geltruacute
La Garrotxa Olot i comarca
La Cerdanya Puigcerdagrave i comarca (en proceacutes)
Alta Ribagorccedila El Pont de Suert i comarca (en proceacutes)
Baix Llobregat Gavagrave Viladecans Sant Boi i Cornellagrave (inicial)
Vallegraves Oriental Granollers Les Franqueses i Canovelles (inicial)
Osona Vic Manlleu Mancomunitat la Plana i comarca (inici)
Terres de lrsquoEbre (inici imminent)
2 districtes de Barcelona ciutat Besoacutes i Esquerra de lrsquoEixample
Sabadell
Local partnerships
working now
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
58
Pilot project with Barcelona city council Objectives
The main purpose is to build a framework to improve the interaction
between social and health services
It wants to define a model to share information between both services
replicable to other entities in Catalonia
This project wants to promote continuity of people attendance by using
information and communication technologies (ICT)
Model of exchange factors
Legal framework
Health and social information sharing
Model of exchange
ICT infrastructure
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
59
Legal framework
REGULATIONS IDENTIFICATION AGREEMENT The ldquoFramework agreement has been signed between the Health Department and
the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona
CONSENT Informed consent to ask the citizen authorization to share their health and social
information
PERSONAL IDENTIFICATION NUMBER The ldquoPersonal Identification Numberrdquo has been established as the common
identifier in health and social systems
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Health and social information sharing
60
Category HCCC (Shared Medical History of
Catalonia) SIAS (Social Service Information System of
Barcelona)
ID information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
Census
Services information
Professionals
(general practitioner nurse)
Health centre palliative care home care nursing homes
Professional (social worker)
Social services centre
Supplementary information
Economic information pharmaceutical copayment
Legal incapacity process date guardian
Health information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability recognized level kind of disability disable scale
Dependent people recognized level
Risk alert (coronary heart disease fall s)
Needs assessment
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brodys index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours before)
Medical discharge documents
AampE documents
EMS (emergency medical services )documents
Services
Home care services
Telecare
Food assistance
Day care centres
Community care
Programsprojects Programsprojects
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
The social data domain
Is an open domain of the Clinical Dictionary that includes
Types of service
Status of requests
Scales of evaluation
Environment devices
Social diagnosis (problems)
We are mapping all this concepts to SNOMED CT in order to obtain a semantic standard
That guarantees the exchange the information from different sources without losing its meaning
And allows us to uniquely identify represent compare translate and exploit it
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
62
ICT infrastructure
The project wants to build a framework to improve the interaction between social and health services by using information and communication technologies (ICT) Moreover It focuses on person-centered care
This model exchange take the health technical model as a reference
Web Services are used for providing structured information and to make easier the integration of the workstations in the health and social centers
The health professionals can view social information requested of a citizen The social professionals can view health information requested of a citizen
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
A Web Service is a method of communication between two electronic devices over a network This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona)
Technological terms
Security Common repository
Informed consent will be signed by
the citizen The health or social professional will
send the document to the common repository Each professional can check if the
citizen has signed this consent
Informed consent will be custodied
in a common repository It will be validated by both systems It will do periodic checks
Send informed consent
and check
Health Departament Information System
Social Service Information System
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
65
Stakeholders commitment
Developing a strong theory of change shared and
supported for the policy level
Subsidiarity principle Local partnerships
Challenge 1
Challenge 2 Long term thinking for short term problems
Ensuring an assembler role
Challenge 3 Make something happen
Multilevel approach - Disruptive strategy amp Start up
methods
Challenge 4 Workforce role transformation
Professional leadership and consensus strategies
Challenge 5 Citizenship involvement
Redefining the citizens role
Learnt lessons
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
Implementing community-based integrated care in practice
Towards a collaborative model of integrated care in Tona
gencatcat
gencatcat
