HOW THE ACG RISK STRATIFICATION TOOL IS BEING USED IN THE VENETO REGION FOR CASE FINDING PATIENTS WHO MEET THE PROJECT S ELIGIBILITY CRITERIA

Transcription

1 CAREWELL HOW THE ACG RISK STRATIFICATION TOOL IS BEING USED IN THE VENETO REGION FOR CASE FINDING PATIENTS WHO MEET THE PROJECT S ELIGIBILITY CRITERIA FRANCESCO MARCHET, PROJECT MANAGER VENETO REGION - LOCAL HEALTH AUTHORITY N.2 FELTRE

2 SUMMARY Overview of the CareWell project The Veneto Health and Social Care model The JHU ACG System and its deployment in Veneto The tool developed by LHA Nr.2 Lessons learned 2

3 PROJECT OVERVIEW CareWell aims to enable the delivery of integrated healthcare to frail elderly patients through comprehensive multidisciplinary programmes. ICTs will facilitate the coordination and communication of healthcare professionals and support patient centred delivery of care at home. The project supports the integration of care in six European Regions. The CareWell project is co-funded by the European Commission within the ICT Policy Support Programme of the Competitiveness and Innovation Framework Programme (CIP). 3

4 CAREWELL VISION Objective: provision of integrated care for frail elderly patients through ICT enabled healthcare services coordination, patient monitoring, patients self-management and informal care givers involvement. Target population: older people who have complex health and social care needs, are at high risk of hospital or care home admission and require a range of high-level interventions due to their frailty and multiple chronic diseases. 4

5 CAREWELL APPROACH 5

6 CAREWELL TARGET POPULATION PALLIATIVE$CARE,$ CARE$COORDINATION$ $$ CASE$MANAGEMENT CARE$COORDINATION DISEASE/CASE$ MANAGEMENT DISEASE$ MANAGEMENT DIAGNOSIS HEALTH$ PROMOTION$ SCREENING End$of$life Multimorbidity and$complexity Single# complex disease, Multiple#simple conditions Single# non3complex condition Symptoms development In##good health Age 65 years At least 2 chronic diseases (COPD, Diabetes and/or CHF] Fulfilling local/national criteria of frailty: increased vulnerability, complex health needs and at high risk of hospital or care home admission Able to understand and to comply with study instructions and requirement independently or with the help from a carer 6

7 CAREWELL PARTNERS Kronikgune (SP) Osakidetza (SP) Powys Health Board (UK) Institute of Rural Health (UK) Puglia Region (IT) HDFEZ Farmakoekonomika (CR) Lower Silesian Marshal s Office (PO) Veneto Region (IT) Region Syddanmark (DK) Empirica (GE) HIM SA (BE) Ericsson (HR) Faculty of Electrical Engineering (HR) 7

8 THE VENETO S SOCIAL AND HEALTH CARE SYSTEM Veneto Region delivers healthcare and social care through 23 Local Health Authorities and 2 Hospital trusts that compose the Veneto Region s Social and Health Care System. The Veneto s Model of Care has a long history of integration between health care and social care, in fact since 1992 the local branch of the Region in the field of care are called Local HEALTH and SOCIAL Authorities. Veneto has also been striving for the integration between primary and secondary care. The Local Health and Social Authorities manage both Hospitals and Districts, functional structures that manage primary cares, (GP, Nursing Homes, Home Nursing Services, Social Services ). 8

9 THE LOCAL HEALTH AUTHORITY NR.2 OF FELTRE The Veneto s pilot site of CareWell is hosted at Local Health and Social Authority N.2 of Feltre [ULSS N.2], supported by Consorzio Arsenàl.IT, Veneto s research centre for ehealth Innovation. ULSS N.2 covers a mountainous area of 935 km2, serving inhabitants. The 23% of the population is over 65 years old and the 11% is over 75. The Ageing index is 177%. 9

10 THE LOCAL HEALTH AUTHORITY NR.2 OF FELTRE ULSS N.2 delivers health and social care through a second level hospital (400 beds), an hospice (7 beds), a physical rehabilitation center (45 beds), a functional structure dedicated to the needs of primary health care, elderly care and social care called Social and Health District. More than the 14% of the over 65 y.o. population receives In-home cares, from the Social and Health District professionals. ULSS N.2 coordinates also 56 GPs, 10 pediatricians, 24 pharmacies and the activities of 15 nursing and care homes (both public and private), hosting about 1200 citizens. 10

11 INTRODUCING THE ACG SYSTEM ACG [Adjusted Clinical Group] is a population grouper used for risk adjustment developed by Johns Hopkins University in Baltimore [USA] with 3 key goals: Stratify the population and their risk; Integrating data to integrate points of health service delivery; Improve care coordination for persons with multi-morbidity. The main strengths of the ACG System are: Population focused Evidence based Comprehensive Personalized Inter-sectorial approach Continuity 11

12 PERSON CENTERED DATA COLLECTION Disease registries (ICD9) Emergency Room (ICD9CM) Nursing homes & Hospice (ICD9CM) Home care (International Classification for Primary Care - ICPC) PERSON Hospital discharge data (ICD9CM) Mental Health Database (ICD10) Rare disease registry (ICD 9) Drugs (ATC) Costs & tariffs (DRGs, tariffs, drug costs) 12

13 REFLECTING THE CONSTELLATION OF HEALTH PROBLEMS EXPERIENCED BY A PATIENT Time Period (e.g., 1 year) Treated Morbidities Visit 1 Visit 2 Visit 3 Diagnostic Codes Code A Code B Code C Code D Morbidity Groups ADG10 ADG21 ADG03 93 ACG Categories Clinician Judgment Clinical Grouping Age and gender 6 RUBs categories 13

14 INTEGRATION OF DATA FOR INTEGRATED CARE POPULATION DISEASE : Diagnoses (EDC, major EDC) Drugs (RxMG, major RxMG) DIAGNOSES DRUGS ACG SYSTEM DISEASE BURDEN ADG (Aggregated Diagnosis Groups) ACG (Adjusted Clinical Groups) RUB (Resource Utilization Bands) - COSTS - RESOURCE USE - TREATMENTS FUTURE USE OF RESOURCES Future cost prediction Probability of high cost Probability of hospital admission 14

15 THE STRATIFICATION OF THE POPULATION PALLIATIVE0 CARE,0 CARE0 COORDINATION0 00 CASE%MANAGEMENT CARE% COORDINATION DISEASE/CASE% MANAGEMENT 5=0 End0of0life0=001%0 40=0Multimorbidity and0 complexity =030% 30=0Single0complex disease,0 Multiple0simple conditions =017% RUB%5 WEIGHT%10,2%%% RUB%4 WEIGHT'5,1''' RUB'3 WEIGHT'2,4'' DISEASE%MANAGEMENT DIAGNOSIS 2#=#Single#non!complex condition 16%00 1#=#Symptoms development =##44#% RUB'2 WEIGHT'0,9''' RUB'1 WEIGHT'0,3 HEALTH%PROMOTION% SCREENING 0=#In##good health=##18% RUB'0 WEIGHT'0''' HEALTH MANAGEMENT TOOLS LOCAL WEIGHTS = COSTS 15

16 STRATIFICATION & USE OF RESOURCES % POPULATION % TOTAL COSTS 16

17 USING A POPULATION RISK-ADJUSTMENT TOOL TO INTEGRATE HEALTH SERVICE DELIVERY IN REGIONE VENETO Pilot : 2 LHAs (1 mln inhabitants) Local database building Statistical validity Study on GP databases integration Initial Deployment : 6 LHAs (2 mln) Retrospective analysis on markers Analysis on specific chronic conditions Predictive modeling for hospitalization Interface of ACG with BI tools Mainstreaming : 21 LHAs (5 mln) Regional database building Support to case management for chronic patients in primary care 17

18 USING A POPULATION RISK-ADJUSTMENT TOOL TO INTEGRATE HEALTH SERVICE DELIVERY IN REGIONE VENETO Pilot : 2 LHAs (1 mln inhabitants) Local database building Statistical validity Study on GP databases integration Initial Deployment : 6 LHAs (2 mln) Retrospective analysis on markers Analysis on specific chronic conditions Predictive modeling for hospitalization Interface of ACG with BI tools Mainstreaming : 21 LHAs (5 mln) Regional database building Support to case management for chronic patients in primary care 18

19 THE TOOL ULSS N.2 has implemented a stratification of patients through casemix and risk adjustment software John Hopkins University ACG combined with a powerful business intelligence tool such as QlikView. 19

20 THE TOOL 20

21 THE TOOL 21

22 THE TOOL 22

23 THE TOOL 23

24 THE TOOL 24

25 THE TOOL 25

26 THE TOOL 26

27 LESSONS LEARNED Huge amount of data registered for administrative purposes has become a gold mine to support integrated care. Entering data without any feedback can be annoying, but by giving to clinicians and strategist, a valuable return can increase the accuracy enabling a virtuous circle of cooperation. In order to integrate care it is fundamental to start to integrate projects and experiences as in this case: the results of combining different efforts gives back not only a bare sum of them 27

28 THANKS TO The CareWell Project Consortium and its coordination team lead by Kronikgune; Dr. Maria Chiara Corti, dr. Massimo Fusello and the ACG Working Group of Veneto Region; The local implementation team at ULSS N.2 Feltre. 28

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