Innovations in primary care: CASAP experience
Antoni Peris – Grao, MD
CASAP CEO
EHMA Board Member and PC SIG Chair
EFPC Advisory Board Member
VI SESSIONE Il distretto come sede di governo dei percorsi integrati e complessi
Needs and services
Citizens
Patients
Community
Population
Health
Social
MÚTUES I SERVEIS
PRIVATS
20%CENTRES PRIVATS
10%
COMPRA SERVEIS PROVISIÓ“PLA DE SALUT”
Catalan Health System
7
P O P U L A T I O N
Castelldefels: 66.375EAP Can Bou: 33.089
CASAP
CUAP: 132.569
8
Primary Care Teams
• Designated Geographical Coverage
• Hired according to goals and financed according to adjusted population
• Salaried Professionals
• Interdisciplinary teams
• List of assigned patients for professionals
• Scheduled consultations, spontaneous demand
• Centre, home, community
• Diagnose, treatment, follow up, promotion, prevention
9
We’re not super humans…
10
…we are “just” a Professional Team:PCT (8 -21h)
• 12 Family doctors
• 2 pediatricians
• 20 nurses
• 1 Social worker
• 13 clerks
• 11/2 odontologist
• 3 nurse aids
PC Emergency Unit (24h/7d):
• 2 Family doctors
• 5 nurses
• 1 nurse aid
• 2 clerks
11
Professionals lists: adults
Professionals lists: adults
Professionals lists: children
Management innovation
15
Team: Gateopening
P4P:
Skill-mix
Team:
Subsidiarity
Training: Skill mix
Management innovations
16
Care modelinnovation
17
18
19
Care model innovation
Nurse care intervention in acute situations
20
Accuracy health clerks: 90,28%
Nurses resolution: 74%
Average waiting time: 9,11 minuts
Nurse care intervention in acute situations
21
Spontaneous demand 2017
42.738
Non-scheduledconsultations
22.138 - 51,80% Family doctor
20.600 - 48,20% Nurse
16.985 - 82,45% Autonomously
3.615 - 17,55%
Family doctor consultant
Non-scheduled consultations average duration: 5 minutes
22
UBA
Role
Healthy child
follow up
Acute Care
Professionals
Controls
Pediatric care innovation management
Rigid link nurse - doctor
Pediatricians: Exploration
Nurse: Health education,
techniques
Twin consultation
Exclusively pediatricians
4 pediatricians/4 nurses
20
Independent selection nurse and
doctor by parents
Adapted to activity needs
3 Ped(115,36h)/ 5 nurses (156,38h)
16
Nurse Managing
Two team consultation,
first and last
Nurse: relevance role
Pediatrician: consultant
Coming from Getting at
Responsiveness capacity
CUAP
Wider Service Basket
Clinical innovations
Service basket: Diagnostic Add on
Oral anticoagulant control
Blood pressure holter
Ultrasonography
Allergy studies
Non midriatic retinography and intraocular pressure
Dermatoscopy
Diagnostic management (scanner, RMN, Holter, endoscopies, treadmill test, EMG...)
Service basket: Treatment Add on
Group learning
Expert patient
Case management
Community activities
Minor surgery
Para-articular treatment
New activities
Programa COMSalut: Connectat
Pla interdepartamental d'atenció i interacció social i sanitària (PIAISS)
Pla Interdepartamental de Salut Pública (PINSAP)
E-Healthinnovation
Virtualconsultation
SMS
TICs
E-Health innovation
Creation of a Facebook profile, managed and supported by a pediatric nursing team. Theprofile is aimed at teenagers of Castelldefels, with the objective of solving and clarifyingdoubts that may arise in the easiest and most comfortable way for them.
This profile is known as 'Mar Castelldefels' and is associated with adedicated blog with content and information of interest to young people.The High Schools working on this project are: IES Les Marines, IES J. LluisSert, Sant Ferran and Escola Petit Món-Felissa Bastida.
From March 2012, 328 young people have joined, mainly from SecondaryEducation centers that belong to the Health and School program
Community health innovation
Mar Castelldefels: Salut i Escola
Model de Gestió Infermera de la Demanda ComplexaCare of patients with chronic conditions
Care for patients with complex chronic conditions
Team
Superteam intrateam
Superteam extrateam
Hospital
Issues to consider
Integrality
Patient-centeredness
Longitudinallity
Resolution
Integration / Continuity between care levels
Patients safety
Feasibility
Complex needs Nurse Management (GIDC)
• Goal: improve care of Highly complex or highly dependent patients.
• Close to PCT, identify proactively complex needs’ patients.
• Avaluate needs of patients, main carers and home/nursing home,Planning care and oferign integrated and coordinated social andHealth services.
Target population✓People with complexity and
multiple needs.
✓Comorbidity, multiple non-scheduled hospital admission orE.D. attendance in the abovementioned patients.
✓End of life situation.
✓Highly fragile elderly peopleneeding care from diverse services,including psychogeriatric units oradmission to intermediate carecenters for symptoms control.
✓Care in low prevalence processes,to foster carer empowerment ,(tracheostomy, CPAP, port-a-cat,etc).
✓People without family help or lowself care abilities.
.
FunctionsIndividualized evaluation of patient and home needs
Diagnose of problems: start and develop a coordinated intervention plan togetherwith other team professionals and mobilize resources needed.
Interventions follow up and evaluation .
Treat acute situations according to guidelines.
Inform on Health status, treatment, care and expected results both patient andfamily.
Promote self care.
Family/carer education to get as much independence as possible (awareness ofalarm signs and proceedings).
Identificació del Pacient Fràgil PCC MACA
Valoració Cuidador: Cuidador/a: Competent: Telèfon:Relació: Viu sol: Zarit:
Us segur de la medicacióMedicació: Adherència medicació: Inhaladors:
Efectes secundaris
medicació/al·lèrgies:
Efectivitat medicació: Revisar tècnica inhalador:
Valoració SocialBBAA: SPD Teleassistència:SAD públic: SAD privat: LAPAD:TS de referència: Voluntariat:
Exploració FísicaPA: FC: FR:Sat02: Edemes: P abd.:AC: AR: Pes:Tº:
Control de símptomesDolor (EVA): Nàusees/vòmits: Astènia:Signes Neurotoxicitat: Constipació: Anorèxia/hiporèxia:Malestar emocional: Ansietat/depressió: Insomni:Dispnea: NYHA:
Síndromes GeriàtricsImmobilitat: Inestabilitat i caigudes: Incontinència:Demència i SCA Desnutrició: Alteracions vista i oïda:Restrenyiment: Insomni: Iatrogènia:Immunodeficiències: Lesions cutànies: infeccions:Disfàgia: Nafres:
Valors i creencesDVA: PDA: PIIC: Religió:
AutonomiaBarthel: Lawton&Brody: Pfeiffer/ Lobo:TIRS: MNA: Yesavage:BRADEN Nº Caigudes:
Transició entre nivells/Continuïtat assistencialNº ingressos: Nº visites urgències:Risc de Descompensació: Ingrés Planificat CSS:Subaguts: Visites CUAP: SEVIAC: PADES:
Recomanacions en casa de crisis o descompensació (PIIC)Febre: Dispnea:Dolor: Alteracions consciència:Preferències del lloc on vol ser atès?
Pactat propostes d’adequació del pla terapèutic?
Pactar alguna consideració pel que fa a l’ús de tècniques o instrumentacions?
Consideració en casa de claudicació de l’entorn cuidadors o, si fos el cas, de situació d’últims
dies?
Planificació de decisions anticipades
Altra informació:
Patients with complex chronic conditionsPCC________493 | MACA______179
% Visits by ref. ________________75,41%
GIDC_______________________________40
Active pat.__________27
ICC________________11
PIIC______________40%
Passive pat.____13
NEO__________13
MPOC_________4
PCC + PIIC with recommendations___338
MACA + PIIC with recommendations_152
% PIIC _______________________84,37%
Know more about CASAP
Brugués A.B. , Peris Grao A. et al, Evaluación de la gestión enfermera de la demanda en atención primaria, Atención Primaria, 2015
Peris Grao A., Brugués A.B., Nurse gatekeeping for unscheduled patients in Primary Care, Internation Journal of Integrated Care, 2014
Brugues A., Peris A., Martí LJ., Approche des pathologies aiguës au moyen d'un Guide des Interventions Infirmières, Revue Sociologie Santé 2007; 27
Mentions on CASAP
Improving interprofessional collaboration in primary care: Position Paper of the European Forum for Primary Care
The collaboration of general practitioners and nurses in primary care: a comparative analysis of concepts and practices in Slovenia and Spain
A Better Pill to Swallow - A global view of what works in Healthcare
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