11

Mr. Juan Carlos ContelDr. Jordi Martínez

Catalonian Department of Health-TICSalut

Chronic and Integrated Care in Catalonia

Basis for a Integrated Health and Social Care Plan for Catalonia:

From PPAC to PIAISSPIAISS

The journey from a Chronic Care Program towards a new model of Integrate health and social care

Washington, October 20th 2014

Session structure• A new and different Health Plan and the introduction of a

new STORY • Chronicity Prevention and Care Program: the “journey”

toward Integrated Care

• Complex Chronic Care as catalyst of Integrated Care

• Care management as strategy • Towards a new evaluation framework: The first results

• A new journey toward a new Integrated health and social care model

• ICT developments to support new Integrated Care model.

“i-SISS.cat” contribution

3

The Spanish National Healthcare System

• NHS funded by taxes • Decentralized to regional autonomies• Universal coverage• Free access• Very wide range of publicly covered

services• Co-payment in pharmaceutical products• Services provided mainly in public

facilities• Interterritorial Board to coordinate

policies4

Catalan Healthcare System: some basic features

• Area: 32,106 km2• Population: 7,611,711 inhabitants. 17% over 65 y. (expected 32% in 2050)• 1780 € expenditure per capita and 1150 € public expenditure per capita in 2012 • Life expectancy: 82.27 years• Gross Mortality rate (2010):8/1,000 inh.• Infant mortality (2010): 2.6 /1,000 live births• 369 Primary Health Centres (PHC) ranging from 20-45,000 inh)• 69 “acute hospitals” (no far from 50 Km. from every home)• 96 “long term care” centres (residential homes: long-stay, convalescence,

palliative care)• 41 Mental Health Centres

5

Catalan Healthcare System

USER

USER

SERVEICATALÀ

DE LA SALUT100%

SERVEICATALÀ

DE LA SALUT100%

SUPLEMENTARYPRIVATE

INSURERS 20%

SUPLEMENTARYPRIVATE

INSURERS 20%

INSTITUTCATALÀSALUT (public)

77%

INSTITUTCATALÀSALUT (public)

77%

PRIVATECENTERS

10%

PRIVATECENTERS

10%

CONTRACTED NON-PROFIT PROVIDERS

23%

CONTRACTED NON-PROFIT PROVIDERS

23%

Commissioner Provider

6

Source: Catalan Health Plan 2011-2015.

The Catalan Health Plan 2011-2015

Health Programs: Better health and quality of life for everyone

Health Programs: Better health and quality of life for everyone

Transformation of the care models: better quality, accessibility and safety in health procedures

Transformation of the care models: better quality, accessibility and safety in health procedures

Modernisation of the organisational models: a more solid and sustainable health system

Modernisation of the organisational models: a more solid and sustainable health system

I

II

III

For each line of action, a series of strategic projects will be developed, which make up the 31 strategic projects of the Health Plan.

For each line of action, a series of strategic projects will be developed, which make up the 31 strategic projects of the Health Plan.

9. Improvements to information, transparency and evaluation

1. Objectives and health programs

7. Incorporation of professional and clinical knowledge 6. New model for contracting health care

5. Greater focus on the patients and families

8. Improvement of the government and participation in the system

2. System more oriented towards chronic patients

3. A more responsive system from the first levels

More PHC !!!

4. System with better quality in high-level specialties

Launched at the end 2011

7

Strategic lines of the Chronic Care Program

8

9

An increasing number of elderly

Source: INE, projections 2011

1/3 of population will be over 65 and 12% will be over 80

9

Healthy33%

Chronic non complex62%

Complex3,5%

Advanced1,5% Terminal Bereavement

PREVENTIVE APPROACHCURATIVE APPROACH

PALLIATIVE APPROACH SELFCARE

COLLABORATIVE CARE

Integrated Clinical and Care Pathways

10

• Integrated Care Pathways as a formal agreement among professional clinical

leaders at local level

• Based on reference clinical guidelines and best evidence

practice

• Critical key points identification

• Critical variables uploaded at Shared Clinical record

• 80% of territories implemented 3 of 4 chronic conditions: COPD, depression,

heart failure and DM2. Now Complex Cronic Care Pathways work

• Agreement on different “situations”: 0. Diagnosis, 1. Stable, 2. Acute exacerbation,

3. Management difficulty, 4. Transitional Care

• Other 6 conditions to be included in the future

Integrated Care Pathways

11

Healthy33%

Chronic non complex62%

Complex3,5%

Advanced1,5% End of life Bereavement

PREVENTIVE APPROACHCURATIVE APPROACH

PALLIATIVE APPROACH SELFCARE

COLLABORATIVE CARE

Taking care of complex patients

12

Level 2Chronic patients at risk

Case Management

Disease Management

Self-care suportLevel 1People with stable chronic diseases at early stage

Level 3Complex chronic patients

Comorbidity, emergency hospitalizations, A&E visits, moderate and severe dependency, polypharmacy

HEALTH PROMOTION Healthy people

WHO do we like to identify people at risk?

13

14

PCCMultimorbidity

Severe unique diseaseAdvanced frailty

MACALimited live prognosis Palliative approach,

Advance care planning

Two profiles of complexity

Basic and Priority: “PCC” and “MACA” identification and labelling + Integrated Care Pathway + 24 / 7 model + Carer identification and support

14

- Care centres that have patients classified and marked in these two types, can publish this label/mark in HC3- The classification / label must be visible on all the screens , given the importance of the condition- It has been incorporated in July 2013 version to HC3 stratification with Clinical Risk Groups (CRGs)

PCC: Complex Chronic Patient

MACA: Advanced chronic disease

15

Primary Care

Information from Centres/Hospitals

Specialist Care

Diagnostic Procedures

Diagnostics

Prescriptions

Vaccination

Hospital Discharge Report

A&E Report

Specialist Care Report

Lab Results

RX Report

Other diagnostic reports

Hospital Data

Information from Dep of Health

Electronic Prescription

Diagnoses

Procedures

Discharge Data

Prescription

Medication Plan

“Shared Clinical Record (HC3)

16

“Shared Individual Intervention Plan” (PIIC)

Health problems/Diagnosis Active Medication Allergies Recommendations for “in case of crisis” or

exacerbation Advanced Care Planning Resources and services used Multidimensional assessment Carer whom are delegated decisions Additional information of interest

18

Multimorbidity unified data base

Insured data sourceNIA, demographic data

Diagnosis data baseNIA, tipus_codi, codi, data dx ,UP,

tipus_UP

“Contact” data baseNIA, dates contacte ,UP, tipus_UP,

urgent, CatSalut, T_act.

MDS-Hospital

MDS-PHC

MDS-MH

MDS-NH

MDS-A&E

Central RegisteredInsured

Health Problems

Pharmacy (PHC and hospital provided)

Pharmacy data baseNIA, ATC, data dispensació, unitats,

Import

Mortalitat (INE)

Data sources

Divisió d’Anàlisi de la Demanda i de l’Activitat18

Clinical Risk Groups and levels of aggregationStandard aggregation 1.000 groups (CRG)

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 1,000 groups. Too much !!!

Aggregation in groups

19

Multimorbidity in Catalonia obtained by stratification

20

DM2

COPDDEPRE

OSTEOARTHRITIS

Prevalence of multimorbidity

Heart Failure

21

Stratification and Emergency admission risk

CRG RSCIdentification people at risc

Proactive measures

Classification people at risk

Segmentation for the proactive management of people at risk

Identification and recording at Clinical Record

22

Returning population stratified data base

Chronic disease selectionHospitalizations 

Risk

ID DM HF COPD Asthma Other: Nº emerg

admisssion

Hospital Cumulative

days

CRG (status and

severity)

Emergency admission

rate

Mortality rate

ZAGO234… 1 1 0 0 1 3 18 7.4 80% 40%

ROGU675.. 1 0 1 0 1 1 8 7.3 65% 28%

Selection of patients by different criteriaDifferent pyramids related to different Risk approach:

Future hospitalization / Death / Future cost

23

1% 18% 133% 10.992€ 13% 13% 2% 7% 57% 5.872€ 13% 26%

8% 3% 28% 3.162€ 28% 54%

17% 1% 14% 1.411€ 25% 79%

72% 0% 2% 282€ 21% 100%

POPULATION MORTALITYRATE

HOSPITALI-ZATION RATE

ESTIMATED EXPENSE

% ACCUMU-LATED

Impact distribution of different segments

24

Constructing a new GMA morbidity grouper in Catalonia

Source: CatSalut, 2013

Mortality PHC contacts Hospitalization A&E use

CRG vs GMA CRG vs GMA CRG vs GMA CRG vs GMA

25

Basic assessment in Complex Chronic Patients• Basic standardized and customized assessment: Functional +

Cognitive impairment + Social Risk + Depression• NECPAL assessment to identify “Advanced Chronic Disease” condition• Complementary assessments

26

A “NECPAL Questionnaire” is available to assess “Advanced Chronic Disease” Condition

• “Surprise question” (!): “Would you (the referee clinician) be surprised that patient could die in the next following 12-18 months?”

• Al least another clinical condition indicating bad prognosis

27

Who are the PCC and MACA patients ?

Source: CatSalut, 2013

PCC MACA

28

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.

29

Current situation chronic patient avaluation

Indicators Primary Care Hospital Care

Avoidable Hospital Admissions + -

Home Care program Coverage + -

Health outcomes: good control, process and treatment

++ -

Readmission rate in chronic processes: Chronic Obstructive Pulmonary Disease (COPD) and Heart Failure (HF)

- ++

COPD/HF Avoidable Hospital Admission - -

Discharge planning in “PRE-Discharge” program - +

To ensure continuity care in “POST-Discharge” program

+ -

“Quality of life” (HRQoL) assessment - -

Fragmented care and fragmented evaluation framework

30

New evaluation vision: “Triple Aim”

Population

Health

Experience

of Care

Per Capita

Cost

• Health Outcomes Indicators incorporates in evaluation Primary Health Care (PHC) (good control chronic diseases, vaccination..)

• Quality of life

• Satisfaction

• Patient Reported Outcome Measures (PROM)

• Costs

• Service utilization: Avoidable Hospitalizations , Readmissions,…

Evaluation and commissioning of ”Integrated Care”

?

31

Professional & Managerial System Information You MUST identify an expected prevalence

Benchmark with Team and all organization

Screen display of indicators by doctors and nurses. (!) Monthly data updated !!! Differentiated internal weight among indicators

New contract 2013: Common PHC-Hospital Targets

33

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

SPECIFIC TRANSVERSAL OBJECTIVES (“TERRITORY”) (20%)% minimum PCC/MACA with Intervention Plan (“PIIC”)% minimum PCC/MACA with medication review% minimum PCC/MACA with post-discharge medication conciliationReduction emergency admissions in PCC/MACAMinimum number participants Expert Patient Program% minimum COPD patients with spirometry% minimum PHC with Mental Health integrationPrevalence minimum depresion with “severity” criteria% minimum patients with depresion with “suicide risk” assessmentDevelopment at local level a consultant virtual office“Amputation rate” reduction in DM“Ophthalmology/locomotor “ referral first visits under expected tax33

Figures: 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 100.000 inhab. rate)

Source: MSIQ, Catsalut

709,6

684,1

652,7

620

630

640

650

660

670

680

690

700

710

720

2011 2012 2013

8 %last 24 months

34

Figures: Potentially avoidable hospital admissions for COPD

Decrease by 13,1 % from Dec 2011 to Dec 2013 (24 months)

Availability of evolution of avoidable emergency admissions per region / sector / PHC team (x 100.000 inhab. Tax)

Source: MSIQ, Catsalut

35

Figures: Potentially avoidable hospital admissions for heart failure

Source: MSIQ, CatSalut

Decrease by 3 % from Dec 2011 to Dec 2013 (24 months)

Availability of evolution of Avoidable Emergency admissions per Region / Sector / PHC Team (x 100.000 inhab. Tax)

New trend!Increase by 25% from 2006 till 2011

36

Basis for a Social and Health Integrated Care Plan for Catalonia:

PIAISSPIAISS

25th February 2014:New Government Agreement where is launched a new Integrated Health and Social Care Plan in Catalonia

Accountable and reporting to Department of Presidency

38

Integrated Health and Social Care is high priority and policy in EU (ex: England, Scotland, etc.)

https://www.gov.uk/government/policies/making-sure-health-and-social-care-services-work-together

39

How to conduct a collaborative model?

1. Environmental and internal analysis at local levelMinimum internal and external situation analysis / Identify critical elements enabling the building of proposals to be collected in ‘Local Operational and Functional Plan’ (LFP) / Highly operational guidance and implementability with short terms results.

2. Integrated operational care modelOperational approach promoting common space and time.

3. Define and use a “territorial governance board” Strategic governing body / steering group / implementing group

4. Define a common porfolio for people/users: joint caseloadComplex Chronic care and dependence / Home nursing and home help service (SAD) / Hospital discharge planning / Institutionalized people / Mental health / Childhood at-risk / Abuse / Active aging, health promotion and disease prevention / Other

40

RISK RISK TO DEVELOP COMPLEX HEALTH AND SOCIAL TO DEVELOP COMPLEX HEALTH AND SOCIAL NEEDSNEEDS

COMPLEX HEALTH AND SOCIAL NEEDS

HIGH HEALTH HIGH HEALTH AND SOCIAL AND SOCIAL COMPLEXITYCOMPLEXITY

CO

MPLE

X S

OCIA

L N

EED

S

CO

MPLE

X S

OCIA

L N

EED

S

CO

MPLEX

HEA

LTH

NEED

S

CO

MPLEX

HEA

LTH

NEED

S

1

2

3

45

6 7

Complex health and social needs ?

41

How to conduct a collaborative model?

5. Shared information systems: constructing a “new Health & Social” electronic Record. •Identify the person with the CIP (Identification Number) as a common identifier.•Prior agreement on the coding and register of social problems.•Prepare the local social services information system for it to be ‘interoperable’ in a short-medium term and provide a minimum set of information and variables for a Shared Social and Clinical Record •Access to a minimum set of information and variables of common interest on social field for the Shared Clinical Record of Catalonia (HC3). Later stage: HCSC fed with input from both health and social parties. 1st stage: generation of a Social Intervention Plan incorporated to HCSC. 2nd stage: Shared Individual Intervention Plan.•Communication systems to improve accessibility, messaging and virtual work between social and health areas.•Introduce social variables gradually to available health stratification.

42

“PCC / MACA” condition

Shared Individual Intervention Plan (“PIIC”)

Diagnostics/ Health problems

“Dependency degree” formal assessment

“Home Help” services label

“Telecare” services label

Social Care Intervention Plan

Pharmacy prescription

Health Care Health Care Social Care Social Care

+ Social

“Health and Social” Integrated eCarePilot project in pioneer territories

43

How to conduct a collaborative model?6. Selection of people based on cross-database and lists of people from social and health areas and stratification (!!!)

7. Definition of guaranteed protected pathways in transitions (discharge planning + post discharge support) among services and in crisis situation and proactive planning.

8. Dependence assessment and recognition procedure optimized with a guaranteed maximum response time.

9. Incorporation and definition of roles and responsibilities of different professional profiles (esp. Social workers working in PHC

10. Accountable professional for people with complex needs

44

How to conduct a collaborative model?11. Common and transverse Shared/Single Outcome Framework with incentive alignment. Progressive process. Triple aim vision: health results and good care, service utilization and good perception of care.

12. Definition and implementation of an integrated home care model.

13. Joint action plan for promoting autonomy, active aging, health and well being and disease prevention incorporating the role and collaboration of telecare services.

13. Accessibility solutions and joint technical assistance home aids stores from a territorial perspective.

14. Incorporation of the third sector.

4545

“Microsystems”•Community-based and primary care leadership •Integrated care pathways•Multiprofessional work•Transitional care •Out of hours care•Home care strategy

Joint case / care load: Shared needs assessment + action plan

Stratification models: assessing population needs

Clinical and professional leadership

Health and social care local governance

Shared outcome framework: shared responsibility & join accountability

Aligned incentives: shared vision about the use of resources

Shared Electronic Health and Social record

Person Empowerment and Self-care

ENABLING ELEMENTS

Culture and change management

Catalonian Integrated Care model:Set of elements to support Integrated Care

Multi-lever approach: Multi-lever approach: ALL things at the same timeALL things at the same time

Catalan SystemThe Catalan healthcare is a multi-provider model integrated in a unique public network.

Providers are free to select their information systems; however 85% of the primary care centers have the same system (eCAP)

Interoperability among systems must be guaranteed

Integrated care (health & social)

Decentralized SystemAction to call - Challenges

47

There are two key elements to develop ICT according to the objectives of the Health plan:

Electronic Health Record of Catalonia (EHR)

Personal Health Channel

• Allows organized access to relevant information of different centers health records and to

some central databases of the health system.

• The EHR is not the sum of the electronic records of the healthcare centers; it doesn’t

incorporate all the information from medical records.

• The citizen is the holder of the data contained in its medical record

• He will have access to its health information available in its electronic Health Record

As an information and services network

Deployment of a multichannel network to communicate and interact with the citizen

Action to call - Challenges

48

97%97%

Hospitals

98%98%

Primary Care

82%82%

Long-term care

67%67%

Mental health

Catalonia

Spain

USA

27 hospitals 6

EMRAM

2013

Action to call - Challenges

2 m docs/month

23%

Current model

121.390

access/month

64%

BPMRulesCDSS

IS

Web services

Care processesHealth intelligence

Messagingplatform

BI/visorNew model: ISISS.cat

Health and social integration

Integrated care

processes

Action to call – i-SISS.Cat

i-SISS.Cat

Strategic plan for the implementation and deployment of the platform for the management

of healthcare and social care Processes in Catalonia

52

The i-SISS.Cat solution should allow:

CitizenAccess to healthcare & social informationProvide different services to interact with the systemPersonalize assistancePatient expert communities and e-learning contents

Healthcare & Social SystemAccelerate implementation of healthcare strategy planAllow to transform healthcare model (from Activity towards Outcomes)Analytics tools for the governance modelAllow process standardization

Social & Healthcare Providers

Interoperate with the rest of providersFacilitate the adoption of new payment modelsImplement clinical pathways in every region360 vision of patient Manage the processes and KPIs measurementCollaboration environments

Government programs:

Summary of Processes Governancei-SISS.Cat

•Creation of programs and tracking key performance indicators (KPIs).•Display of results for program and service provider.

360 °view of the patient:• Access to the broad view of the patient and the process •Environments of collaboration between professionals.

Healthcare process integration:• Shared Social and health-related information •MDT platform

Integral vision of the citizen:• Platform that will allow us to expand the coverage to other social benefits and giving coverage to the unique social and health record.

The i-SISS.Cat solution challenges:

53

54

The i-SISS.Cat solution integrated care:

Actions: •Priorisation of chronic conditions groups•KPIs definition at high level•360º vision design per program•Interoperability standards

Outcome Measurement

Patients enrollment

Pathways Implementation and

EHR integration

Integrated Pathways definition

Program creation and KPIs

Actions: •Pathway definition and KPIs•Definition of recommendations

Actions: •Technical development to facilitate data flow and exchange from different providers•Configuration of roles for users

Actions: •Information exchange •360º vision•Alerts definition•Creation of a collaborative environment•Patient monitorization

Actions: •Predictive modeling•Query utilities to select patients at risk•Support decision tool

Roadmap i-SISS.CatACHIEVED IN PROGRESS

The i-SISS.Cat solution overview:

Previous experience in integrated care processes: MECASS Project (based on Cúram)

55

360 holistic vision of patient

•Patient Segmentation and Stratification relevant information (CRGs, labels, etc.)•Clinical Data per program•Resource consumption for each Plan•Program cost (plan vs. real)

56

Global treatment plan

•Access to services and different units for program & provider – best provider for the job• Integrated activities in a patient workspace (interoperability)•Provider billing process based on results / success

The i-SISS.Cat solution areas:

57

The i-SISS.Cat solution areas:

Multidisciplinary Team environment:

•Agreed patient treatment – meeting minutes•Agenda shared for scheduling meetings•Share information and knowledge•Open discussions about the patient: treatment, etc.•MDT meetings management

58

The i-SISS.Cat solution areas:

Measure the impact of each program defined

•Global results: efficiency of program – impact on resources•Impact in the healthcare system•Impact in the patient health•Cost – Benefit analysis•Increase the quality of service: patient perception

59

The i-SISS.Cat solution roadmap:

2016

2014

Kick Off

Interoperability platform

First process definition (PCC)

Measure KPIs

2017-2018

2015

Deployment of services for the citizen

Models advanced analysis, prediction and knowledge management

Third wave of process definition

Measure KPIs

Continuous improvement and calibration

New processes within the model

System deployed to all the country

Measure KPIs

Goal to achieve: a modular solution, that allows to implement the strategic objectives defined in the Health Plan 2011 - 2015

Go Live of integrated process solution

Opening the door to the citizen

Integration of health and social process

Second wave of process definition

Measure KPIs

60

The i-SISS.Cat solution roadmap:

2016

2014

Kick Off

Interoperability platform

First process definition (PCC)

Measure KPIs

2017-2018

2015

Deployment of services for the citizen

Models advanced analysis, prediction and knowledge management

Third wave of process definition

Measure KPIs

Continuous improvement and calibration

New processes within the model

System deployed to all the country

Measure KPIs

Goal to achieve: a modular solution, that allows to implement the strategic objectives defined in the Health Plan 2011 - 2015

Go Live of integrated process solution

Opening the door to the citizen

Integration of health and social process

Second wave of process definition

Measure KPIs

Basis for a Integrated Health and Social Care Plan for Catalonia:

From PPAC to PIAISSPIAISS

Thank you very much for your attention!!!

Washington, October 20th 2014

Chronic and Integrated Care in Catalonia

Catalonian Department of Health-TICSalut

Mr. Juan Carlos Contel

Dr. Jordi Martínez

BACK UP SLIDES

NUCLEAR CARE MODEL

IMPLEMENTATION SUPPORTING GUIDE

Source: PPAC 2013. Departament de Salut

NEWINDIVIDUAL

ACTIONSTEAM

REDESIGN

TERRITORYCOMPLEXITY

CARE PATHWAY

Basic requirements

Optimal provision

Excellence

64

Check list for support of deployment complexity care model

Basic and Priority: “PCC” and “MACA” identification and labelling + Integrated Care Pathway + 24 / 7 model + Carer identification and support

Visualization in Shared Clinical Record and different RISK scores

Morbidity group and RISK calculated and published twice a year

Description of different RISK segments

CRG information (morbidity group), severity and Hospitalization Risk

CRG information (morbidity group), severity and Hospitalization Risk

• CRG 7/5 • 3 emergency

admissions• Hospitalization Risk of

35%

PCC/MACAPCC/MACA

Included in “CASE MANAGEMENT” Program

Included in “CASE MANAGEMENT” Program

CRG and Risk score visualization

PATIENT SELECTION by CRG + Nº emergency admissions last 12 months + Hospitalization RISK next 12 months

Ad-hoc “queries”:Every professional could perform a basic query combining stratification and current chronic conditions and other variables (pharmacy,…)

It could be selected 1 or more chronic conditions

Stratification segment code

List of patients sorted by “gaps”

ID PACIENT “GAP”

New “panel management”introduced

71

•It has been converted information into warnings when we access to clinical record in each visit

•Customized configuration per professional and Team

•Warnings sorted by importance and relevance

•Weekly calculation (“online” proposal)

•“Front-office” and “back office” modality

Mean 20-30% improvement in some scores !

SISAP: Professionals System InformationComparison with Team, area, region and organization in Catalonia

Screen display of indicators by doctors and nurses. (!) Monthly data updated !!! Differentiated internal weight among indicators

• Indicators of admissions for every Sector and Primary Health Team• 14 chronic diseases• Benchmarking with different standards among PHT and Hospitals

Servei Català Salut. División de Registros

MSIQ. Quality measuresMSIQ: http://146.219.25.61/msiq/index.htmlMSIQ: http://146.219.25.61/msiq/index.html

Hospital admissions for ACSC

Monthly udpated information!

Includes: COPD, HF, pneumonia, DM complications, asthma, urinary infections, dehidratation, HTA

Availability of evolution of avoidable emergency admissions for ACSC per region / sector / PHC team (x 100.000 inhab. Tax)

Source: MSIQ, Catsalut

−6,5 %last 24 months

Heart Failure

COPD

Avoidable Emergency Admissions in ACSC

Available information at Primary Health Care Centre level

Diabetes complications

Asthma

30-day readmissions

90-day readmissions

30 and 90 day Readmissions per Heart Failure per area

Variability Atlas related to indicators

Source:Evaluation and Quality Agency

Population based related to Primary care area

Expected per capita expenditureAverage expenditure (€)

Primary Care Pharmacy Emerg.adm. A&E Outpatient ClinicsAGE

Primary Care

Pharmacy

Emergency admissions

Outpatients clinics

Expected per capita expenditureAverage expenditure (€)

Primary Care Pharm. Emerg.adm. A&E Outpatient ClinicsCOPDDiabet. Dement Card. CVAMent. Cirros. Kidney H. Fail. Neopl.VIH

Primary Care

PharmacyEmergency admissions

Outpatients clinics

®METHODOLOGY

Source: Programa Paciente Experto Catalunya® 2006

Continuity of care

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

person-

centred

Empowered citizens

- selfcare

Shared

information

Professional

leadership

Identification and registering (in the community) Community

based care

Case m

an

ag

em

en

t / S

hare

d c

are

Comprehensive

approach

Shared vision

& shared outcome

Information System Tool for Managers in Primary Health Care

Screen where you could monthly monitor health indicators available for Primary Care managers