Innovations in Integrated Care Management: How to Adapt Lessons from - PowerPoint PPT Presentation

Innovations in Integrated Care Management: How to Adapt Lessons from Spain for the US Webinar Slides April 17, 2018

OVERVIEW OF SPANISH INNOVATIONS: INDIVIDUAL AND COMMUNITY CARE PLANS, INTEGRATION IN EMERGENCY CARE AND IN SOCIAL AND HEALTH CARE Núria Mas IESE Business School Jaime Grego Chair of healthcare Management CONFIDENTIAL AND PROPRIETARY Any use of this material without specific permission of IESE Business School is strictly prohibited

CATALAN HEALTH CARE PLAN 2011-2015 Program of Prevention and Attention to Chronicity (PPAC) Integrated Health and Social Plan (PIAISS)

DIVERSE REALITIES Socioeconomic differences Rural and urban realities

CARE PATHWAYS IDENTIFICATION GOALS: OF POPULATION LOCAL AGREEMENTS To obtain the best possible care for the population Proactive : attention to early identify and anticipate crisis Efficiency : use the available resources in the best possible way to achieve the population health goal SHARED SHARED INFORMATION INDIVIDUAL INTERVENTION PLAN (SIIP) 4

CONTINUUM OF CARE FOR CHRONICITY WITH SPECIAL FOCUS ON COMPLEX AND ADVANCED PATIENTS Source: Contel et al. (2015) “Chronic and integrated care in Catalonia”; Int.Journal of Integrated care

IDENTIFICATION OF THE TARGETED POPULATION § Targeted population : patients with complex chronic conditions (CCP) & patients with palliative needs (MACA) § Proactive identification, with clear targets. Initial target of the Plan: 25,000 CCPs identified by 2015. There were 150,000 CCPs identified by May 2015! § WHO CAN IDENTIFY: it can come from anywhere in the system. However, the GP has the final call on the “oficial”codification as such. The primary care team validates and labels. § IDENTIFICATION GUIDELINES: guideline document for professionals § Unique experience objective (algorithm) risk adjustment models and clinical judgement BASQUE COUNTRY: population screening based on algorithms. 43 items in hospital/community module and 23 items in emergency module § Once identified, the primary care team has to guarantee that the patient and her family are informed § Labeling in digital platforms § 6

ONCE, IDENTIFIESD THE LABEL CAN BE SEEN IN ALL DIGITAL PLATFORMS Source: Departament de Salut; Generalitat deCatalunya

4 KEY ENABLERS OF SUCCESS IDENTIFICATION SHARED & LABELING INDIVIDUAL INTERVENTION PLAN (SIIP) STABLE CRISIS 8

SHARED INDIVIDUAL INTERVENTION PLAN (SIIP) § Personalized care plan § Global evaluation of the patient. Takes into account the individual´s physical, social, and psychological needs . § It also takes into account the patient´s values and preferences § Elaborated collaboratively between the GP, the different health-care and social-care professionals (specialist, geriatrician…), and in many cases (for instance, when the patient is highly dependent) the patient´s family. § It is materialized as a dynamic document that gathers all the main medical and social data on the patient that is to be shared. Periodic review depending on the situation of the patient § For MACA patients it contains advanced healthcare directives . § The SIIP is included in the Shared electronic medical records . § It includes care instructions to facilitate decision making among the professional teams that will be treating the patient. Instructions during stable phases and during crisis

4 KEY ENABLERS OF SUCCESS SHARED INDIVIDUAL IDENTIFICATION INTERVENTION & LABELING PLAN (SIIP) STABLE CRISIS § Contact phones, § DURING WORKING HOURS § Relation with the case ‒ First respondent: primary care team management nurse ‒ If necessary, patient will be transferred § Revision of medication to a specialist team § Proposed follow-up services ‒ Hospital admission, day-hospital, emergency care § Recommendations to sustain the stable situation for as long as ‒ All the providers can access the action possible plan through the shared clinical records § Patients and family know about the § NON-WORKING HOURS SIIP and they can communicate so ‒ Call 061, the health hot line when the patient is being visited by ‒ If there is a SIIP, the 061 will act a provider accordingly 10

SIIP– WHAT DOES IT INCLUDE? Advance health-care directives Health problems Multidimensional valuation Primary-care team data Telecare assistance? Current medication Home care? Drug allergies Case management? Lives in a residence? Lives alone? Person in charge Directives in case of crisis Who can make decisions? Update date Additional information

The last date on which information was updated. Update date Automatically obtained from the shared clinical record. Condition code and name, date of diagnosis, severity. Health problems -> Diagnoses Elements can be prioritized and comments can be included. Automatically obtained from electronic prescription system. Starting date of treatment, name Current medication of drug and active ingredients, dosage, treatment duration. Automatically obtained from electronic prescription system. Drug allergies

Free-text field. Includes a summary of the care objectives for the patient and directives to be used in case of a health crisis. Specific recommendations: A list of the most likely crises the patient may have, together with Directives in case of a crisis the most appropriate facilities for treating the patient and specific directives for each possible crisis. General recommendations: Patients’ preferences for treatment location, as well as information on treatments the patient refuses and the people who should be involved in cases of shared clinical decisions.

EMERGENCY CARE AS PART OF THE INTEGRATED CLINICAL PATH 24/7 § 061 Respondents can see the patient label (CCP/ADS) § Qualified 061 professionals (doctors/ nurses) can have access to the SIIP and to the electronic shared medical records § Participate in the local agreements and care pathways § Number of patients for whom 061 has accessed HC3 (2016)

4 KEY ENABLERS OF SUCCESS SHARED INDIVIDUAL IDENTIFICATION INTERVENTION & LABELING PLAN (SIIP) SHARED CLINICAL RECORDS 16

Shared clinical records • They include the labeling of the patient (CCP or ACD)

INDIVIDUAL PORTAL

4 KEY ENABLERS OF SUCCESS SHARED IDENTIFICATION INDIVIDUAL & LABELING INTERVENTION PLAN (SIIP) SHARED CLINICAL RECORDS LOCAL AGREEMENT 19

LOCAL AGREEMENTS § SUCCESS DEPENDS ON THE PATH MORE TAN ON THE PROTOCOL . It is based on the functional integration of all the agents in the territory. § Local focus and collaboration as the key to implement best practices § Development of Integrated care pathways (ICP) § Local written and formal agreements between local leaders Integrated Care Pathways Elaboration process and local agreements § A group of experts at the national level set the conditions to target § An ICP is a way to organize all § A second group of experts in a people involved in the care local level use this core key process elements and then add ad hoc § The strongest feature of the ICP § The final pathway is transmitted is its flexibility to adapt to the to CatSalut different characteristics of the territory 20

CURRENT STATUS Criteriaavailability of intermediate care units % of regions Explicit written agreement 87% Agreement between agents to respond to crisis 90% Description of a model of home care 48% Description of a model of long-term-care facilities 29% Explicit agreement of care during transitions 80% Availability of “day hospital” units for chronic patients 90% Availability of expert units to assist primary care in complex 79% cases Availability of intermediate care units 72% Source: CatSalut http://salutweb.gencat.cat/web/.content/home/ambits_tematics/linies_dactuacio/model_assistencial/atencio_al_malalt_cronic/documents/arxius/do c_complexitat_final_5.pdf

RESULTS(I) Avoidable hospitalization rate: Osona vs. synthetic control 1.1 1 45% .9 Reduction .8 .7 2008 2010 2012 2014 2016 Year Osona synthetic control unit Source: Mas & Masllorens (2018) “Impact on Health Outcomes from Integrating Health and Social Care”

RESULTS (II) 30 days readmission rat: Osona vs. synthetic control 1.2 1.1 1 9% .9 Reduction .8 2008 2010 2012 2014 2016 Year Osona synthetic control unit Source: Mas & Masllorens (2018) “Impact on Health Outcomes from Integrating Health and Social Care”

State Innovations and Payment Reform Center for Medicare and Medicaid Innovation April 17, 2018

The CMS Innovation Center Statute “The purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care furnished to individuals under such titles.” Three scenarios for success from Statute: 1. Quality improves; cost neutral 2. Quality neutral; cost reduced 3. Quality improves; cost reduced (best case) If a model meets the statutory requirements for expansion, the statute allows the Secretary to expand the duration and scope of a model through rulemaking. 2 2