b3 action group maturity matrix for integrated...
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Brussels, 10 March 2015
Josu Xabier Llano Hernaiz [email protected]
B3 Action Group Maturity Matrix for
Integrated Care
European Summit on Innovation for Active and Healthy Ageing
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• The Basque region has a population of 2.2M • High life expectancy, resulting in an increasingly aged
population (>18% over 65). • Universal health coverage is provided through taxation at
an annual cost representing over 30% of government budget.
• Healthcare is provided by the Basque Health Service, Osakidetza, with 320 primary care centres, 12 acute hospitals, 4 chronic care hospitals, and mental health services.
• Workforce over 25,000, directly employed by the government
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• ‘top down’ leadership: Integrated Care Plan for the Basque Country risk stratification, common information systems (Osabide Global, Osarean, BI, telemonitoring services, telecare services) organizational integration (Integrated Healthcare Organizations)
• ‘bottom up’ leadership engagement (local pathways, stakeholder coordination, innovation activities) coordination of care processes.
Areas of innovation
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Estrategia del Departamento de Salud
Plan de Salud 2013-2020
Estrategia de Osakidetza
Estrategia Sociosanitaria
MARCO ESTRATÉGICO:
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Plan de Atención Integrada en Euskadi
� La atención integrada es un principio de la
organización de cuidados sanitarios para mejorar
los resultados de salud , mediante la integración
de los procesos asistenciales. Se trata de dar
coherencia y crear sinergias entre los
diferentes niveles del sistema sanitario para
lograr cuidados: menor fragmentados , más
coordinados, más eficientes, de mayor calidad
� En Euskadi se utiliza el concepto de
“Organización Sanitaria Integrada (OSI)”
para referirse a la creación de estructuras que
han surgido para solventar las consecuencias de
la fragmentación y la falta de coordinación entre
los diferentes niveles asistenciales,
principalmente entre AP y el ámbito hospitalario.
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Capacity to change 5 Population based health plan, Estrategic plans for Health Department, Osakidetza, Socio-Health Estrategic plan
Structure&Governance 4
IHO (integrated healthcare organizations created by decree, Office for monitoring evolution of changes in integration, chronic care model evolution, new model of contract program that boosts integration actions
Use of Information&Infrastructure 5 Electronic Health record, Personal Health folder, telehealth infraestrcuture, Social-health information system, telecare service
Standardisation 3 Common clinical pathways, common clinical guide lines
Inhibitors 3 Governance decree, disemination/engagement activities (world café), new strategic plans
Population Approach 4 Stratification tool, new teams to develop prevention and promotion actions,
Evaluation Methods 4 IEMAC, D´AMOUR, Contract program, Pilots assesment, technology assesment service (Osteba)
Breadth of Ambition 4 PAINNE program, Integration at structural and clinical levels
Innovation Management 4 Contract program, calls and grants, new directorate for innovation and research, PAI
Capacity Building 4 bottom-ups projects funded by the Department of health, good practice awards in Osakidetza, Kronikgune, BIOEF, Osteba, SIAC
Finance & Funding 3 Bundled payment (Primary and specialized care) and common objectives. Organitational incentives
Citizen empowerment 3 School for patients, Active patient program, Kronet, Acces to PHR
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Capacity to change
Structure&Governance
Use ofInformation&Infrastructur
e
Standardisation
Inhibitors
Population Approach
Evaluation Methods
Breadth of Ambition
Innovation Management
Capacity Building
Finance & Funding
Citizen empowerment
MATURITY MATRIX
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3. TICs
Oganizational
aproach
Strategy for
integrated care
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2010
2011
2014
2015
2016
RSM BIZKAIA
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Clinical Pluritatológicos, IC, EPOC y Diabetes 2013 - 2014
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3. TICs
Technical aproach
Strategy for
integrated care
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Actividad no presencial Actividades no presenciales
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News Activity Communication
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• Improves the quality of patient care reducing medication errors • Promotes medication therapy management and support care coordination
across various providers • Improves patient compliance and avoid over-the-counter drugs • Reduces costs by actively promoting appropriate drug usage • Automatic checking of drugs interaction and allergies improves accuracy
and help to prevent adverse effects • Easier for patients . Save time. Different choices to get their medicines
Electronic prescription
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PRESBIDE: UNIVERSAL PRESCRIPTION
GP
PSIQ
CAR
RESP
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SINGLE PHARMACOTHERAPEUTIC HISTORY
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Treatment Plan
Osabide
Che
mis
t
Dispenser point
Hospital Primary Care Mental Health
Prescription Electronic signature
Prescription Point of Care
Health Insurance Card
Unification
of Medication
Treatment Plan
Easy Less visits GP
Health inspection endorsement
Automatic renovation
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TREATMENT PLAN
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Enero-Octubre 2013 Enero-Octubre 2014
4.881.534
10.433
8.597.759
14.314
1.028.259 846.018
Enero-Octubre
2013
Enero-Octubre
2014
Nº de evolutivos
Nº de usuarios
Nº de pacientes
Ebook del paciente
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Atención Primaria Atención Especializada
Año 2014 hasta octubre 39.622 Duplicando la actividad
del 2013
3% de todas las interconsultas
Evolutivo Consultas No Presenciales Primaria Especializada
Interconsultas no presenciales entre AP y Hospital
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Enero a Octubre de 2014
18% de las
consultas de adultos
Consultas Telefónicas
1.634.402
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Mi Historial Clínico
Informes clínicos
Datos de Filiación
Próximas Citas
Historia Clínica en QR
Autoseguimiento
Subida de documentos
Gestión de mi enfermedad crónica
Diario del paciente
Dudas con mi médico
Mensajes al paciente
CARPETA DE SALUD (años 2012-2014)
! Consultar y recuperar la información 1
Enriquecer su propia información 2 Nuevas vías de relación Paciente-Profesional 3
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Balanced scorecard for health management
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9 Facilitar la colaboración entre los profesionales de la OSI 9 Favorecer la continuidad asistencial entre AP y AE 9 Mejorar la calidad asistencial y la atención del paciente
pluripatológico
Irún y Hondarribia: 82.000 habitantes Navarra (5 villas): 8.000 habitantes
OSIs en Euskadi: diseño y resultados preliminares
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¿Qué es la UCA?
Una unidad asistencial que trata de dar atención integral y continuada, a pacientes complejos, pluripatológicos. Trabajamos en colaboración atención primaria, atención especializada y servicios sociales.
¿Quienes forman la UCA?
Internistas de referencia
Enf. asistencial y de enlace
Médicos y enfermeras de AP
Enfermeras gestoras de caso
Trabajadores sociales
OSIs en Euskadi: diseño y resultados preliminares
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análisis 1 año análisis 2 años
0
500
1000
1500
2000
2500
3000
INGRESOS ESTANCIAS URGENCIAS
311
2717
588
194
1532
344
ANTES
DESPUÉS
-37,62 %
-43,61 %
-41,49 %
0
500
1000
1500
2000
2500
3000
INGRESOS ESTANCIAS URGENCIAS
362
2977
619
227
1720
378
ANTES
DESPUÉS
-37,29 %
-42,22 %
-38,90%
226 PACIENTES 124 PACIENTES
OSIs en Euskadi: diseño y resultados preliminares
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* No toma en cuenta inversiones, farmacia, salud mental...
Gasto per capita (euros) Gasto en Atención Primaria (%)
AP
Atención especializada
OSIs en Euskadi: diseño y resultados preliminares
Plan de Atención Integrada en Euskadi
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EVALUATION TOOLS
�ARCHO
�CONTRACT – PROGRAM
�D´AMOUR FRAMEWORK
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The ARCHO is an instrument for self-assessment of healthcare organizations with respect to their degree of readiness to cope with chronicity. It is based on the CCM and has been specifically developed for national health system environments. It allows assessment across a variety of organisational settings and levels: macro (decisions on healthcare policies and resource allocation), meso (management of health organizations, large centres and programmes) and micro (practices of healthcare professionals, e.g., in health centres or multidisciplinary proyects)
EVALUATING INTEGRATION MODELS: ARCHO
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ARCHO
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D AMOUR
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Eskerrik asko Thank you
Muchas gracias