Scale up of Integrated Care & Telehealth in Catalonia: Josep Maria Argimon, Director of the Agency for Health Quality and Assessment of Catalonia June 2015 Deployment strategies for the period

2 Integrated care means different things to different stakeholders  To the user, it means a process of care that is seamless, smooth, and easy to navigate  To the frontline provider, it means working with professionals from different fields and coordinating tasks and services across traditional professional boundaries  To the manager, it means merging or coordinating organizational targets and performance measures, and managing and directing an enlarged and professionally diverse staff  To the policymaker, it means merging budgets, and undertaking policy evaluations which recognize that interventions in one domain may have repercussions on those in other domains, and thus should be evaluated as part of a broader care package The concept of integrated care is considered as one of the most promising solutions, if not the necessary way forward to assure the sustainability of the healthcare system, through reinventing care delivery structures around the needs of the citizens

3 Integrated care, for who?  People with complex health and social needs.  In Catalonia, there is a group of people, around 8%-10%, which present or may present health and social needs, not easily separable, and the cost of their care represents a high percentage of the budget. Risk stratification optimizes the delivery of integrated care by analyzing the needs of patients in the target groups to predict risks and tailor the services to the needs of the patients

4 Key issues to ensure an integrated, people-based care 1.Developing shared information systems across the multi-professional team (including both health system and social workers). Shared electronic medical records, clinical decision support systems and risk stratification methods are useful tools to achieve integrated care. 2.Enhancing the ability to measure outcomes by making available the results at the provider level should be central to any plan to integrate; to determine success or identify areas where further improvements are needed. 3.Assessing experiences to identify and scale up best practices, support care co-ordination across care pathways, and reduce unwarranted variations or gaps in care. 4.Promoting patient engagement in taking decisions about their own care. 5.Implementing aligned financial incentives that support providers to work collaboratively by avoiding any perverse effects of activity-based payments. 6.Implementing multi-specialty groups of health and social care professionals in which generalists work alongside specialists and social workers to deliver integrated care.

5  Universal health care card with unique personal identifier, operating since It has to be used in all health contacts  80% of primary care centers use the same IT system (eCAP)  Hospital IT systems diversity is much greater  Since 2005 Shared Electronic Health Record (HC3) project. Created to share information between the different IT systems, 100% of primary care centers and hospitals connected to it  Currently sharing 100 million documents, both structured and semi structured data (Diagnosis, Clinical Procedures, Lab tests, Medical image (100% digitalized), Drug prescription (100% digitalized), etc). 1. How healthcare IT landscape is organized in Catalonia Constructing a new eClinical and Social care record Next step

6 2. Measuring outcomes enhancing transparency and accountability to all citizens The mission of the Central de Resultats (outcomes report) is to measure, evaluate and disseminate the results achieved by the different healthcare centres: primary care, hospitals, long-term and mental health and addictions.  It offers of an integral, comprehensive and transparent system for measuring and evaluating the results achieved by the different healthcare agents.  It aims to be the reference instrument for citizens, providers and administrators.  It allows making providers accountable for their outcomes, and fosters comparison between suppliers, promoting benchmarking and sharing best practices.

7 Example: Hospital care report  60 indicators on 7 dimensions: Patient centred care Appropriateness Effectiveness Patient safety Efficiency Sustainability Research and teaching  Indicators centre by centre (63 hospitals)  Information about the number of cases, adjusted indicator, and confidence intervals Ranking with the centres with best and worse results “Voice of the Expert” “Best practice” Citizens version Interactive tool, and open data

8 Example: Hospital care report Effectiveness indicators,

9 Measuring outcomes enhancing transparency and accountability to all citizens  Assessment of clinical pathways: diabetes, chronic obstructive pulmonary disease (COPD), cardiac insufficiency, hip fracture,…  Territorial analysis of health outcomes Next steps

10 3. Identifying best practices. The Observatory of Innovation in Healthcare Management in Catalonia The aims of the Observatory are to collect, validate and organize the innovative experiences that are being developed in our system It offers an innovation community web page fostering interaction among more than 450 health professionals who exchange their experiences.

11 Identification of elements of success that make up the systemic projects Teledermatology Adequacy of prescription in primary and community health care Online Preop Process of identifying and extending best practices Key drivers to identify the best practices are not only based on the reduction of costs of healthcare but also on the benefits of innovation in terms of improvement access and scalability to other settings.

12 Example: Teledermatology What is it?  Consists of a procedure that begins when the primary health care physician photographs a questionable skin condition on a patient and attaches it to the patient’s medical history. Next a virtual visit is scheduled in the dermatologist’s diary and the dermatologist replies to the physician with the diagnosis and the treatment. What advantages does it offer?  Reduces time and costs for patients by avoiding trips to the hospital  Contributes to reducing the time between diagnosis and treatment allowing resolution to be optimized in primary health care. Economic impact?  Reduction has occurred in the waiting lists for specialist care and a reduction in referrals to specialist care (average days on the waiting list for specialist care has fallen from 30 to 16).

13 4. Patient empowerment through a shared decision making model Integrated care requires a partnership between patients and professionals, working together to select tests, treatments and support packages based on patient preferences, clinician experience and research evidence.

14 5. Payment model focused on results  Payment mechanisms and incentives will need to be aligned across providers and between health and social services. Inconsistencies in the way that different providers/levels are reimbursed and incentivised continue to reinforce fragmentation in the delivery of care.  Bundled payments (episode-based payment) have been proposed as a way to encourage coordination across providers and to promote more efficient care..

15 6. Inter-ministerial Social and Health Care and Interaction Plan  Inter-ministerial Social and Health Care and Interaction Plan. Promoted by the Government of Catalonia (Government Agreement, February 2014) with the participation of the Presidential Ministry, the Ministry of Social Welfare and Family and the Ministry of Health.  The aim is to catalyze necessary actions to accomplish an integrated system that guarantees social and health care to people who have care needs of both services. This plan wants to: o Contribute to the sustainability of the current welfare system o Guarantee the best use of resources o Guarantee a preventive, proactive, planed, personalized, coordinated and adapted to the individual health and social needs care The Catalan Healthcare System has a good level of coordination between providers and between levels of care. However, when we focus on the coordination between healthcare and social care we have opportunities for improvement

16 Implementation project. Local partnerships for integrated care

17 Catalan Model of Health and Social Integrated Care Core & enabling elements Health and social care local Partnerships Person Empowerment and Self-care

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