#INTEGRATED CARE@HOME AMADORA S EXPERIENCE Adriano Fernandes Projects Manager&Consultant Slide 1
0. AMADORA: Challenging Territory 1. MISERICORDIA OF AMADORA a) Culture&Services b) Impact c) Management d) Social&Healthcare Services 2. BEYOND SILOS a) European Framework b) Purpose&Goals 3. Amadora s Approach@Home a) Scope b) Service Process Model c) Training on Heathcare&ICT d) Monitoring Tools&ICT Devices e) Gains of Scale&Quality 4. Change Management&Sustainability a) Change Management b) Sustainability c) SWOT d) Lessons Learnt Slide 2
0. AMADORA_CHALLENGING TERRITORY Slide 3
AMADORA_An Overview Lisbon suburb 23,8 km² 175.558 inhabitants Diabetes_in between 20-79 (7,2%) Death by Stroke(17,7) -national rate=11 Hypertension (19,8%) 16.000 unemployed people 30.000 with low education skills 19% agedover65 42% aged over 75 15% ofyoungpeople 35.000 immigrants, 20% of the universe Death by isquemic cardiac disease(15,6 )-national rate=10,7 CRITICAL INDICATORES #HEALTH Tuberculosis (49,1) Death by Cervical cancer(20,4) -national rate=3,4 Slide 4
1. MISERICORDIA OF AMADORA #30 Years Serving Well the Community Slide 5
MISERICÓRDIA DA AMADORA To provide, create and develop appropriate social services in the community of Amadora, promoting solidarity, quality of life and human dignity. Respectfor humandignity, Social accountability, Ethics, Humanization and Quality of the Services provided, Sustainability, Innovation Health(CLIMA / U.C.C./ UAC), C&Y( 4 Children Day CareCenters,3 KinderGarden,1 School,19 EC Centers), V People(MIT; Social Enterprise, CLDS, SocialStore),Elderly(2 NH,2 DCC, 2 HCS) 5300 Clients daily Slide 6
TARGET/CLIENTS: EVOLUTION Clients ratio per year 2012/2014 2011 2008 2007 2006 2005 0 1000 2000 3000 4000 5000 6000 Clients Slide 7
IMPACT IN AMADORA COUNCIL Slide 8
ORGANISATION CHART Slide 9
SOCIAL&HEALTH CARE SERVICES Social&Economical Disavantadged Individuals/Families Minimum Income; Local Contractfor Social Development S&H Care Services Social Elderly 2 NursingHomes; 2 DayCare Centers; 2 Home Care Support Services First Line CLIMA Health Second Line Long Term Care Unit, Residential Houses Slide 10
2. Taking integrated care one step further... Slide 11
13 Partners 8 Countries 7 Pilot Sites EnablethequalityofLifeandsenseof security and confort to elderly people living@home Delivering of integrated care to elderly people to support them to live independently within the community -Quality of Life - Self Care - Integration of Services - Cross Sectorial Teams - ICT Tools - Evaluation Slide 12
3.AMADORA S APPROACH@HOME Slide 13
BEYOND SILOS_SCOPE 20 Equipments & Devices 46 Formal Carers 150 SCMA Clients 127 Informal Carers 2 Collaborative Platforms(Trai ning+ Online Portal) Slide 14
INTEGRATED LT HOME CARE SUPPORT Entering into service Receiving continuous personalised care Leaving service Entry point (1): Referral by SCMA/Commu nnity Assessment of care recipient s needs for long term home care Enrolment to BeyondSilos service (ICP- LTCare) Initial integrated care plan Coordination of integrated care delivery / revision of initial integrated care plan Personalised multiprovider service package On-site / home provision of informal care On-site / home provision of formal social care On-site / home provision of formal health care Remote provision of health & social care (telehealth, telecare) Shared documentatio n of home care provided Exacerbation / deterioration in functional status managed at home Monitoring / review / reassessment of care recipient s needs Temporary admission to institution (e.g. respite care) Exit point: Disenrollment from BeyondSilos service (ICP- LTCare) Majpr exacerbation / deterioration in functional status leading to hospital admission Pathway: Integrated Home Support after Hospital Discharge Pathway Slide 15
BEYOND SILOS_Technological Adaptation Slide 16
TRAINING: Formal&Informal Carers Mod.1- Welcome&Initial Expectations Mod.2- Role&Statute of the Carer Mod.3- Communication Mod.4-ADL Satisfaction@Home Mod.5- ADL Satisfaction@Personal Mód.6- Biomedical Approach Mod.7- Telemonitoring&Portal Mód.8- Tele-Assistance Slide 17
PREPARATORY PHASE: Database&Informed Consent INFORMED CONSENT DATABASE Slide 18
TECHNOLOGY ON THE FIELD Equipments Devices Online Platform Slide 19
ENROLLMENT STATUS Amadora Num. patients enrolled in BeyondSilos Enrolled for evaluation Intervention group - new care Enrolled for evaluation Control group - usual care Foreseen in TA 150 150 150 Current 150 150 150 Amadora Number Detail user type Eg, GP etc Healthcare providers 10 4GP s 2 Nurses (1 Chief-Nurse) 2 Psychologists 2 Physiotherapists Social care providers 41 5 Social Workers 36 Family Assistants Informalcarers; volunteer support 115 Relatives 12 Volunteers Slide 20
GAINS OF SCALE&QUALITY DIMENSIONS BEFORE BS AFTER BS SERVICES PROVIDED HR INVOLVED Social Care(Higyene&Food+Meds) Formal Carers(Social Workers+ Family Supporters) and Informal (Relatives&Volunteers) Social&HealthCare&Health(Monitoringof Vital Signs+Intervention) Formal Carers(Social Workers+Nurses+Physioterapists) and Informal Carers SERVICES SPECIFICATIONS Meals+Cleaning+Meds+Tele-Assistance + Telemonitoring(weight,bloodpressure, temperature, blood sugar)+ Contact Center ICT&TRAINING Tele-Assistance Tele-Assistance+Telemonitoring+Training (b-learning) PROCESSES MANAGEMENT @Clients Home @Clients Home+Remotely INFORMATION MANAGEMENT Home made Databases Reports on Papper Inexistenceof structuredplanningof Home Care Visits Structured&Electronic Data Bases Electronic&On Time Reports Structured&Electronic Home Care visits scheduling Slide 21
4.CHANGE MANAGEMENT&SUSTAINABILITY Slide 22
CHANGE MANAGEMENT End Users &Carers Organisations Vital Signs Monitoring Stress&Anxiety reduction On site&remote Monitoring Services Linking Communication Security&Comfort enhancement More Time for what really matters Real Time storage and spreading Faster Decisions Slide 23
EMBEDING&SUSTAINABILITY Open mind /new mind-set for new Services on Integrated Care Change Management internalization Wide pool of Stakeholders Nourish Care Badalona Serveis Assistencials University of Twente Portuguese Ministry of Health In progress @ Amadora with Amadora Municipality; Ministry of Health and Portugal Telecom Opportunity of Network of Smart Cities EIP-AHA Commited Region Gains of Scale for End-users in terms of the quality of the Services provided Boosting of SCMA culture and cooperation in between BS Team Boosting of synergies within Departments of SCMA Gains of Scale in terms of knowledge and Tools/Devices regarding Formal/Informal Carers Slide 24
6. BEYOND SILOS_SWOT Intersectorial consortium Expertise in social/health and ICT areas Integrated intervention on services delivery Territorial & target group characteristics STRENGTHS WEAKNESSES Lackofprevious experiences in this specific field Adaptation of end users to ICT solutions Activities/Tasks overloadingofsocial & Health care professional Stakeholders involved Model transference leveraged on new services delivering OPPORTUNITIES THREATS Internal organisational changes in PT Telecom Socio-economical crisis Slide 25
LESSONS LEARNT t Monitoring/Supervision on going Communication & Feedbacks Services Linking Faster Decisions Dematerialisation of Information Added value in terms of the Quality of Services provided Integration of Departments within the Organisation Collaborative work in between Partners Gains of scale in terms of time saved and tasks Importance of trust, mutual support and tolerance Complementarity and non duplication of work Integration of Services Services boosting/new upcoming Services Slide 26
ESKERRIK ASKO! MUITO OBRIGADO! THANK YOU SO MUCH! Adriano Fernandes Email: adrianofernandes@misericordia-amadora.pt Mobile : +351 96 254 94 90 Slide 27