Esteban de Manuel (Kronikgune) CareWell Project coordinator 30 September 2016, Bad Hofgastein, Austria

Size: px

Start display at page:

Download "Esteban de Manuel (Kronikgune) CareWell Project coordinator 30 September 2016, Bad Hofgastein, Austria"

Anastasia Williams
5 years ago
Views:

2 19 TH EUROPEAN HEALTH FORUM GASTEIN DEMOGRAPHICS AND DIVERSITY IN EUROPE NEW SOLUTIONS FOR HEALTH REALITY MEETS REALITY EIP-AHA INTEGRATED CARE AND SHARING EXPERIENCE FROM IMPLEMENTING INNOVATIVE SOLUTIONS: CAREWELL PROJECT - Esteban de Manuel (Kronikgune) CareWell Project coordinator 30 September 2016, Bad Hofgastein, Austria

6 Regions deploying healthcare services: Basque Country (Osakidetza) Wales (Powys Health Board) Puglia Region Lower Silesian Marshal s Office Veneto Region Croatia

3 6 Regions deploying healthcare services: Basque Country (Osakidetza) Wales (Powys Health Board) Puglia Region Lower Silesian Marshal s Office Veneto Region Croatia Zagreb-Ericsson Scientific organisations: Kronikgune HiM, S.A Empirica RSD Faculty of Electrical Engineering Zagreb IFIC (new partner) HDFEZ Farmakoekonomika IRH (only in Y1) 2

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 Elderly people with multiple chronic diseases who have complex health care needs, are at high risk of hospital or care home admission and require a range of high-level interventions

5 Carewell approach Health System Social worker Home Patient Healthcare professionals Carer Patient identification and target group management 1. Integrated care coordination pathway Social and health care coordination/communication and information sharing 2. Patient empowerment & home support pathways Follow-up, monitoring Patient and informal caregivers empowerment

6 STUDIED POPULATION users involved in CareWell which 860 will be evaluated Total Intervention Control Total data Basque Country Croatia Lower Silesia Puglia Veneto Powys

7 Patients characteristics Age, mean (sd) Total Female Male 77.6 (7.7) 78.4 (7.9) 76.9 (7.3) 6

8 Organisational models WHO is involved in caring for and supporting patients, WHAT functions these actors perform, and HOW different ICT tools facilitate the delivery of these activities. Phone Integrated EHR Phone Therapeutic plan Pharmacologic follow-up Tests Follow-up visits Clinical assessment Clinical consultation Therapeutic plan Pharmacologic follow-up Tests Adherence to recommended shared clinical pathways Phone Integrated frail assessment Patient training/education, sel-care empowerment, coaching Organization, coordination Coordination with social care Referral community/home care nursing Adherence to care pathways with care team Telecardiology Follows stable patients Uses ICTs to support delivering healthcare and out-patient clinic for chronicity Adherence to care/clinical pathways shared with Care team Increased, progressive improvement in self-managing his/her chronic condition, involvement in decisionmaking process, pro-active attitude Phone Support specialist in delivering and managing activities Follow stable patients Activates a process of intense disease and care management Promotes team work supported by ICTs Referral to hospital Telehealth/telecare Empowered as stable patient Can be activated using n-118 and telemedicine devices by GPs, specialists, nurses, patients, caregivers, family. Phone SMS Prepare hospital discharge report Therapeutic plan Post-hospital stay follow-up Prepare hospital discharge report Therapeutic plan Post-hospital stay follow-up Clinical consultation Therapeutic plan Pharmacologic follow-up Tests Adherence to recommended shared clinical pathways Phone SMS Hospital care and cure Safety and pharmacovigilance Information and training of patients, caregivers and family on the specialist s hospital discharge prescription. Phone SMS Empowered as stable patient Follows patient in hospital pathways Puglia

9 Basque Country Croatia Lower Silesia Veneto Puglia Powys

10 Self-assesment To define the degree of maturity of eight key factors of integrated care Detect weakest points & improvement areas

11 Improvement areas

12 CareWell pathways Stable patient out of hospital care Unstable patient out of hospital care In hospital care Hospital discharge preparation GP Primary Care Patient identification (at home or healthcare centre): Assessment Therapeutic plan Follow up Additional resources needed? * Social Care * * * Telecare Centre GP / Primary Care nurse Secondary Care Emergency Primary Care Clinical assessment Therapeutic plan Home care? ehealth Centre * Scheduled admission Reference internist * Assessment Clinincal interventions Therapeutic plan Emergency Secondary Care * Day hospital Integrated social assessment Hospital nurse Social resources Hospital Social worker Social Care Social assessment Yes No Yes No Cardiologist Other specialist Pulmonogist Specific empowerment programmes Social resources Ehealth centre Telemonitoring Home hospitalization Reference internist (interconsultation) ehealth Centre Stable patient? Stable patient, additional resources needed? Yes Secondary Care Reference internist Home hospitalization Sub-acute hospital admission Primary care nurse Primary Care Follow-up: Therapeutic plan Patient training Assessments Tests Unstable patient? Yes No Yes No * Reference internist Secondary Care Coordination with Primary Care Follow-up planning No Secondary Care Discharge report (electronic) Hospital nurse 11

13 ICT tools Lower Silesia

14 Differences with usual care Services Electronic prescription Basque Wales Puglia Croatia LSV Veneto Messaging clinician <--> Patients Electronic Health Record Interconsultation Call Center Virtual Conference Personal Health Folder Nurse Information System (record of nursing care) Educational Platform Collaborative Platform Telemonitoring Multichannel Centre (Management Telecare Programs)

15 What is now different? Integrated care pathway is enhanced: Identification of frail elderly patients. Baseline comprehensive multidimensional assessment. Patients planned follow-up Increased role of nurses and GPs as care managers Coordinated hospital discharge: Improved transition Better communication between professionals Data stored and available

16 What is now different? Patient empowerment and home support: Personal Health Folders Personalised programme of integrated care Mobile app to access EHR for the district and specialist nurses to use when they make visits to patients homes. Telemonitoring services. Single databases with information for community services. Education for patients, formal and informal care givers

17 Lessons learned FACILITATORS TECHNICAL FACILITATORS ORGANIZATIONAL FACILITATORS ADMINISTRATIVE FACILITATORS ECONOMIC FACILITATORS USE OF TECHNOLOGIES ALREADY IMPLEMENTED CO-DESIGN WITH END USERS APPEALING USER EXPERIENCE TECHNICAL LITERACY SYNERGIES AMONGST PROFESSIONALS /ORGANIZATIONS ALIGNMENT WITH EXISTING PROGRAMS OR STRATEGIES SUPPORT OF LEAD CLINICIANS IN DESIGN AND PLANNING PARTICIPATION OF TOP MANAGEMENT IN DESIGN OF INTERVENTION SUPPORT OF POLICY MAKERS COMPLIANCE WITH EXISTING POLICIES, LAWS AND PLANS CO-FUNDING BY THE EUROPEAN COMMISSION LONG TERM BUSINESS VIABILITY ANALISYS SERVICE FREE OF CHARGE FOR PATIENTS TECHNOLOGY MATURITY OF VERTICAL INTEGRATION FRANCESCO MARCHET AZIENDA ULSS N.2 FELTRE PROJECT ASSEMBLY, TREVISO, FEBRUARY 18 TH 2016

18 BARRIERS TECHNICAL BARRIERS ORGANIZATIONAL BARRIERS ADMINISTRATIVE BARRIERS ECONOMIC BARRIERS ADAPTATION TO NEW TECHNOLOGY MATURITY OF THE ICT SOLUTIONS INTEROPERABILITY COMPLEXITY OF HEALTH AHD SOCIAL CARE SYSTEMS RESISTANCE TO CHANGE REQUIREMENTS FOR TOOLS ADOPTION PUBLIC PROCUREMENT MANAGEMENT OF MULTIPLE CONTRACTORS LEGAL AND ETHICAL PROCEDURES ECONOMIC CRISIS AND TRENDS PLANNED BUDGET VS REAL BUDGET FINANCIAL PROCEDURES IN PUBLIC ORGANIZATIONS INTEGRATION OF DIFFERENT ORGANIZATIONS TELECARE, EHEALTH AND mhealth FUNDING POLICIES FRANCESCO MARCHET AZIENDA ULSS N.2 FELTRE PROJECT ASSEMBLY, TREVISO, FEBRUARY 18 TH 2016

dynamic SYSTEMATIC evaluation to analyze trends Use of administrative databases Apply Budget Impact

19 Evaluation High cost Organizational models Difficult to deploy (Time) Need to be assessed in daily routine Impracticality to conduct clinical trials Adoption curve has an S shape Organizations are dynamic SYSTEMATIC evaluation to analyze trends Use of administrative databases Apply Budget Impact Analysis adapted to the local context to develop a tool within the Deming s plan-do-check-act (PDCA) cycle 18 3

20 Evaluation framework 19

21 Budget impact analysis 20

22 Discrete event simulation model 21

23 RCT SIMULATION MODEL Control Group Intervention Group A&E HR Interv/Control =0,69 (0,53-0,91) Bernabei R, Landi F, Gambassi G, et al. Randomised trial of impact of model of integrated care and case management for older people living in the community.bmj : British Medical Journal. 1998;316(7141): Deployment Organizationally set objective (Delphi study) Reduction in emergencies by 2% annually with the goal or reducing by 10% in 5 years horizon 22

24 BUDGET IMPACT ANALYSIS 23 11

25 EVALUATION 24

26 CONCLUSIONS All stakeholders needs accounted for when defining new organizational models. New care pathways have to be integrated into day to day practice: care as usual Professionals role changes; requires a reorganization of tasks and new skills Involvement of decision-makers to facilitate new organization and working procedures and encourage up taking new responsibilities. Learning curve: It takes time and resources, facilitate them! BIA and predictive modeling help evaluation and decision making.

27 Thank you!

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

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 -