Post on 19-Feb-2017
Innovation in care for chronic conditions
Integrated Care
Valencia Reference Site ***Dr. Bernardo Valdiviesovaldivieso_ber@gva.es
- Introduction
- Good practice
- Scaling up
Overview
2
An introduction to the Valencia region
An introduction to Department LA FE
4
•Population: 300.000
– > 65 years old: 17,3%
– 9 Health Areas
•Health System
– Hospital for tertiary care: 1
– Hospital for chronic patients:1
– Primary Care Centers: 18
•Human resources
– Hospital: 6.800
– Primary Care: 350
•Activity:
• 35 % basic; 65% reference
•Budget: 600 M€
An introduction to Department LA FE
• Integrated Health Care Organization
• Unique Management System
• Alternatives to traditional hospitalization
• Health Information System. “Level 6 Emram scale”
Triple Aim
Transforming The Model
- Introduction
- Good practice
- Scaling up
Summary
9
Disease management:
Patients with medium level of need• Moderately-complex chronic conditions
Supported self care
Patients with low level of need•Low-complex chronic conditions
Pro
fess
ion
al
Ca
reP
rofe
ssio
na
l C
are
80%
5 %
15%
Case management
Patients who need a intensive level of attention•Highly-complex chronic conditions•End of life conditions
Innovation in care for chronic conditions
10
C. Inc
lusi
on
Case management
Phone-visits
Doubts & alerts
Coordination
Geriatric assessmentCare Plan
Intensive Education
Ambulatory CareHome Care IB <30
Hospital at Hone
Hospitalisation
Hospitalisation Complex
Ambulatory Care
Complex Hos
pita
lisa
tion
LO
NG
–M
ED
CA
RE
Inc
lusi
ón
CareProfessional
Self-CarePatient
Caregiver Self- Control
TransitionCare
Adapting care processes. "Case Management"
Patients
included
Randomization
Branch A
Control Group
198 patients
Branch A
Control Group
198 patients
Branch B
Case Management
198 patients
Branch B
Case Management
198 patients
Branch C
Case Management
Technology Nomhad
99 patients
Branch C
Case Management
Technology Nomhad
99 patients
No
intervention
No
interventionInterventionIntervention InterventionIntervention
Process
analysis
Process
analysis SatisfactionSatisfaction
Respources
consumption
Respources
consumption
SecuritySecurity
Intervention
Cost
Intervention
Cost
MortalityMortality
Intervention
Cost
Health-
related
Quality of
Life
Assessment. Clinical Trial
12
Assessment. Clinical Trial
Usual Care Integrated Care
Patient call every three weeks during working hours
(8-15h)Patient Call every 15 days and 24/7 covered
Patient social evaluation during hospital stay and
during inclusion in CMP
Patient social evaluation during inclusion, and every 4
months in new care model . Closer follow-up
Physiological measurement when patients
receives/goes GP visits
Physiological measurement sent by patient every
week through PC tablet
Educational intervention during inclusion in CMPEducational Intervention at the inclusion and during
follow-up (trough PC tablet or presentially)
Transitions care from STC to LTC focused in clinical
care
Transitions care has both perspectives Clinical and
social
- Introduction
- Good practice
- Scaling up
Summary
15
Disease management:
Patients with medium level of need• Moderately-complex chronic conditions
Supported self care
Patients with low level of need•Low-complex chronic conditions
Pro
fess
ion
al
Ca
reP
rofe
ssio
na
l C
are
80%
5 %
15%
Case management
Patients who need a intensive level of attention•Highly-complex chronic conditions•End of life conditions
Scaling up 1/5
16
30% implemented30% implemented
Gestión de Enfermedad:•Pacientes crónicos de complejidad moderada
• Monorgánicos
Autocuidados:•Pacientes crónicos de baja complejidad
•Factores de riesgo
80%
5 %
15%
Gestión de Casos•Pacientes crónicos de alta complejidad,
pluripatologicos”
•Pacientes en fase final de la vida
Cu
ida
do
Pro
fesi
on
al
Cu
ida
do
Pro
fesi
on
al
Scaling up 2/5
Scaling up 3/5
“Smart e-health platform”
“Real World Evidence”
Scaling up 4/5
Scaling up 5/5
“Real World Evidence”
Innovation in care for chronic conditions
Integrated Care
Valencia Reference Site ***Dr. Bernardo Valdiviesovaldivieso_ber@gva.es