Good Practices in Social Security Good practice in operation since: 2010 PRADO Post-hospitalization Home Return Assistance Programme A case of the National Sickness Insurance Fund for Employees Special mention, ISSA Good Practice Award - Europe competition 2016 National Sickness Insurance Fund for Employees France Published 2030 www.issa.int
1 Summary PRADO (Programmes d accompagnement du retour à domicile après hospitalisation) is a program that aims to shorten the length of hospital stays to meet the needs of patients who wish to return home sooner. It is means of reducing the average hospital stay, in order to improve cost efficiency in hospitals and the quality of overall patient care. PRADO was implemented in 2010. It relies on: intervention of counsellors from the National Sickness Insurance Fund (Caisse national d assurance maladie (CNAM)) during the hospital stay; voluntary registration of eligible patients (depending on the specific program and its progress) with the consent of the medical team; coordination of independent homecare professionals intervention following hospitalisation, in addition to social services, if required. PRADO consists of several programs, each with a distinct focus depending on the type of hospitalization: 1. maternity, launched in 2010 and completed in 2012; 2. orthopaedic, launched in 2012 and completed in December; 3. cardiac insufficiency, launched in December 2013; 4. chronic obstructive pulmonary disease and chronic wounds trialled in May and December 2015 respectively. CRITERIA 1 What was the issue/problem/challenge addressed by your good practice? Given the difficulties that arise when patients return home after a hospital stay, the National Sickness Insurance Fund has implemented support programmes for hospitalized patients on their return home. Programmes to improve the care of patients upon release from hospital have been developed in many western countries who have realized that as our health systems are often compartmentalized, the transition generates breakdowns in patient care and inefficient use of resources.
2 CRITERIA 2 What were the main objectives and the expected outcomes? Launched in 2010 by the National Sickness Insurance Fund, the objective of the PRADO program was to anticipate patient needs on returning home and to make the transition from hospital to home more fluid. These issues are addressed by the Stratégie nationale de santé (National Health Strategy), which organizes community-based health care that: offers patients optimal conditions upon their return home from hospital according to their state of health and their desires; responds to growing desire on the part of patients to return home as soon as it is no longer necessary for them to be in hospital, and enables them to do so; adapts and re-enforces post-hospitalization support: support the progress of medical techniques that en able the development of ambulatory procedures and shorter hospital stays; provides optimal conditions for the return home and avoid unnecessary hospitalization by adapting patient care plans to patient needs; avoids re-hospitalization because of inadequate post-hospitalization care. This program is also based on the need to improve the efficiency of the hospital treatment system. For example, France is ranked 23rd among OECD countries in terms of the average length of stay in hospitals for maternity care (4.3 days as compared to 3.2). CRITERIA 3 What is the innovative approach/strategy followed to achieve the objectives? During its development, it became clear that a better organisation of the hospital-to-home transition could: Support and promote the reduction of the duration of hospital stays; For example, the PRADO maternity program operates as follows: When the medical team has set and approved the departure date of the young mother a CPAM counsellor visits the maternity unit and offers to put the patient in contact with an independent midwife for homecare visits.
3 If the patient agrees, the CPAM counselor organizes the first home visit for the day after the patient leaves the hospital (a second visit will be scheduled 24 to 48 hours after the first). The counsellor may also assist the young mother in any administrative procedures (registering her child as a dependent, registering the parents, online services, etc.). During her visits, the midwife monitors the health of the baby and mother, helps the mother to carry out initial care of the newborn and provides advice and answers to her questions. Avoid unnecessary costs on post-hospitalization measures; Prevent re-hospitalization and aggravation of the patient s condition as a result of inadequate post-hospitalization assistance. CRITERIA 4 Have the resources and inputs been used in an optimal way to achieve the set objectives and the expected outcomes? Please specify what internal or external evaluations of the practice have taken place and what impact/results have been identified/achieved so far. Evaluation mechanisms have been established for each program and combine: An analysis of the program and its immediate effect on post-hospitalization care based on the reimbursement data available in the Système national d information interrégimes de l Assurance Maladie (National Database of Sickness Insurance Funds). Qualitative surveys of patients and health professionals. An impact evaluation with specific protocols put together with the health professionals participating in the development of the various program strands. Maternity results: The program has enabled the effective implementation of Haute Autorité de Santé (National Health Authority) Recommendations (equivalent to NICE in the United Kingdom) which provides for two mid-wife visits for standard discharges - 72 to 96 hours after birth - with one, ideally, within two days (average time of 1.7 days compared to 4 days in the control group) without reducing access to gynaecologist, generalist and paediatric services as was feared. In 2013, patients who had signed up to the program had slightly shorter hospital stays than other mothers who were eligible for the program.
4 In orthopaedics there has been a similar decrease in the time taken for independent health professionals to take over the patient s medical care following their discharge from the hospital (in the case of independent physiotherapists, 2.5 days compared with 4.5 days in the control group). The average stay for a hip replacement decreased most in establishments where the PRADO orthopaedics strand has been implemented (down by 3.8 per cent compared to a reduction of 2.8 per cent in establishments across France as a whole). The rate of recourse to follow-up and rehabilitation continued to decrease in PRADO establishments between 2012 and 2013 (down 2 points) but remained unchanged overall elsewhere. In the case of patients with heart failure, (pending the outcome of the evaluation launched at the end of 2015 with patients who were part of the programme in 2014 based on a protocol drawn up with the Société française de cardiologie (Cardiology Society of France)) initial trends indicate that the trial has led to an improvement of post-hospitalization care compared to that of the control group: 73 per cent consulted their doctor and 85 per cent had at least one visit from a nurse in the week following their hospital stay (compared with 54 per cent and 56 per cent in 2012), and 59 per cent consulted their cardiologist in the following three months (compared to 31 per cent); the frequency of contacts with other professionals is also higher; Medication management has also improved, with an increase in the number of patients under dual or triple therapy in the first two months (dual therapy: beta blockers + ACE inhibitors, 45 per cent compared with 39 per cent; triple therapy: diuretics + beta blockers + ACE inhibitors, 43 per cent compared with 38 per cent). These results have yet to be confirmed with a larger number of patients for 2014 (approximately 700). CRITERIA 5 What lessons have been learned? To what extent would your good practice be appropriate for replication by other social security institutions? The PRADO program is an external coordination mechanism for field health professionals who offer new services for insured individuals. The program has an effect both on hospitals and with independent health professionals by addressing the compartmentalisation of hospital and non-hospital care. This tool was developed with the support of experts and the Haute Autorité de Santé to coordinate care following hospital discharge for large numbers of patients and draws on [all the] (human) resources available to the health insurance system. The evaluation of the impact of the PRADO programme was aimed specifically at determining if the programme has had any negative impacts on consultations (gynaecological and paediatric
5 for the maternity strand) and on re-hospitalizations. This was not found to be the case and there is evidence of strong patient adhesion and satisfaction. The aim is to extend the PRADO program to include all surgical procedures.