Badalona Serveis Assistencials The Chronic Care Model in BSA Jordi Piera Badalona Serveis Assistencials, Catalonia Barcelona, 17/06/2015 Badalona Serveis Assistencials

Chronic Care Model - Aims The main objective of the CCM programme is to offer an integral care model through the provision of social and healthcare services, to patients with multiple chronic conditions, based on the optimization and integration of resources to give a fast response to the needs of the inhabitants in the region. Specific objectives: Position the patient in the middle of the care model Plan and realize the interventions focused on identify, prevent and treat in advance the acute episodes to avoid further hospitalizations Design and realize individual integrated care plans based on the evaluation of each particular need and the integral geriatric evaluation (VGI) Promote the independent life of those patients as much as possible maintaining good quality of life Coordinate the work of the interdisciplinary teams doing the interventions Guarantee and provide a continuum of services Badalona Serveis Assistencials

Catalonia region - Contextualisation Source: Department de Salut. Generalitat de Catalunya (2012). Badalona Serveis Assistencials

Case management – Integrated care Case management is the procedure where the nurse coordinates the provision of care to guarantee the accomplishment of needs, through the control of symptoms and the management of the most adequate resources, to empower the autonomy of patients. Badalona Serveis Assistencials

How did we organize it – Integrated care Nurse leading the coordination Multidisciplinary teams doing continuous assessment and reassessment of needs Different pathways / programs have been put in place to tailor them according to the patients needs Put the patient in the middle of the care process Engage the family and the community assets within the care process Continuous evaluation to improve the services provided Homecare Department to coordinate the provision of services Badalona Serveis Assistencials

Regional case management model Regional model, no service segmentation. Integration and regional focus Predictive stratification tool available regionally-wide Proactive enrolment of users into the program Case Managers at every Primary Care Centre and at the Homecare Department Within the Regional Case Management, GPs keep being responsible of the patients Continuous evaluation process Coordination between healthcare levels, social care, third sector providers, external providers, etc. Badalona Serveis Assistencials

Stratification tool 9/19/2018 ACT Programme

Stratification tool 9/19/2018 ACT Programme

Stratification tool 9/19/2018 ACT Programme

Some outcomes from the CCM Regional Case Management Program: Characteristics of the patients: 76 years ratio, 52% woman, 1,38% prevalence, 20% with social problems, 67% more than 10 drugs, Interventions done: 86% VGI, 76% flu vaccine, 85% pneumococcus vaccine, 54% ATDOM program, 78% full assessment program Results: 12% reduction GP, 8% reduction nurse (PC), 40% reduction emergencies, 56% reduction of non-programed hospital admissions, 23% increased QOL, 89% increased satisfaction with the service, 59% increased death at home Badalona Serveis Assistencials

Badalona Serveis Assistencials Conclusions The initial driver of CCM in this case was a policy commitment towards a patient-centric model which would enable the continuum of care at a local level (municipality) Reorganisational process and the governance mechanism established have been the main drivers of CCM Health and social care professionals play a leading role in facilitating CCM deployment Interoperable information systems has fostered the full deployment of CCM Absence of major conflicts between the distribution of resources and the alignment of incentives Badalona Serveis Assistencials

Badalona Serveis Assistencials Some highlights – CCM Achieving a full deployment of CCM programs is a slow process It’s better to start with health services and then integrating it with the social services Problems for achieving it are organizational and cultural Expect huge resistance from professionals Integrated common care pathways should be developed A continuous review process should be put in place to keep monitoring and improving the services / programs IT is a tool that will help you within the process, but not the solution (EMR. SCR, ICR and shared care plan are central) Proper quality and cost-benefit evaluation needs to be conducted Badalona Serveis Assistencials

Regional Case management - Case manager activities Activity Amount Phone calls 33% Home visits 24% Self-management 31% Primary care visits 10% Other 2% Badalona Serveis Assistencials

Badalona Serveis Assistencials Challenges No alignment between the Catalonian Health Plan and the purchaser of services -> still buying by activity such as discharge Improve the liaison with health assets available within the Community to deal with the social problems (exclusion and isolation) The role of the internist Link with sub-acute units Badalona Serveis Assistencials

Badalona Serveis Assistencials Thank you! Jordi Piera Jiménez Director of ICT and R&D&i jpiera@bsa.cat - http://www.bsa.cat/international Cell.: +34 651041515 Skype: jpieraj Badalona Serveis Assistencials