p. salvadori overall presentation of the healthcare system in the region of tuscany

OVERALL PRESENTATION OF THE HEALTHCARE SYSTEM IN THE REGION OF TUSCANY

Piero Salvadori

RETOS

Tuscany Region Directorate-General Services to people in the territory

Lodz – Polonia, 26.02.13

Index of the presentation

1. National health service

2. Tuscan health service

3. Tuscan Regional Planning for chronic diseases

4. The Chronic Care Model: how it works

5. The results of chronic care model (CCM)

6. The primary health care centres (PHC X CCM)

Seventh Framework Programme Regions of Knowledge Health Grant agreement no: 266262

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National Health Service born in 1978

Before there were insurances for categories of citizens (workers, salesman, professionals….).

Some citizens were without health care.


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LOCAL HEALTH AUTHORITIES

From 1978 to 1992 in Italy there were 659 Local Health Authorities ( 40 in Tuscany Region)

Since 1992 to today we have 228 local health authorities ( 12 in Tuscany Region)


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1992 2ND REFORM Local Health Authorities become

similar to private company headed by a General Director

the budget of LHA must be in balance. If it isn’t the Director General may be dismissed, and with him the health director and administrative director


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In 2001 is modified our constitution :

So, the Italian Regions can

independently organize health within

its territory. There is the possibility

of having 21 different health systems


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Italy is divided in 21 Regions

We are here


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REGIONS Number of Local Health Authorities

LHA (Company) Hospital Companies

ante 502/92 31/12/1995 01/05/2002 31/12/1995 01/05/2002

Piemonte 63 22 22 7 7

Val d Aosta 1 1 1 - -

Lombardia 84 44 15 16 29

Bolzano 4 4 4 - -

Trento 11 1 1 - -

Veneto 36 22 21 2 2

Friuli Venezia Giulia 12 6 6 3 3

Liguria 20 5 5 3 3

Emilia Romagna 41 13 13 5 5

Toscana 40 12 12 4 4 Umbria 12 5 4 2 2

Marche 24 13 13 3 4

Lazio 51 12 12 3 3

Abruzzo 15 6 6 - -

Molise 7 4 4 - -

Campania 61 13 13 7 8

Puglia 55 12 12 4 6

Basilicata 7 5 5 1 1

Calabria 31 11 11 4 4

Sicilia 62 9 9 16 17

Sardegna 22 8 8 1 1

TOTAL 659 228 197 81 99


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FINANCING Citizens pay taxes Central government

Local Health Authorities Regions



Health Organization in Italy

Public

75%

Private

25%

There aren’t any insurances



DISTRIBUTION OF ECONOMIC RESOURCES

Primary care


1. National health system







•The Tuscan Healthcare System: some data •3,7 millions inhabitants

• 17 Public Health Authorities: 12 Local Health Authorities and 5 Teaching Hospitals organized in three Network “Area Vasta”:

• North West Area Vasta: 2 T.H. and 5 L.H.A. • Center Area Vasta: 2 T.H. and 4 L.H.A. • South East Area Vasta: 1 T.H. and 3 L.H.A.

• 2.940 GPs (1200 patients on the average)

[2009]



In Tuscany Region:

•Free of charge: hospital admission and care, home

care, prevention assistance.

•With ticket payment:

• Specialist visits and exams

• drugs


Tuscan regional planning

Face chronic

epidemic

How ? With chronic care model

Where ? Into Primary Healthcare

centres in territory, Health

Clinic (Case della Salute)

With whom ? General Practitioners,

Nurses, Administrative

Personnel, Social Workers


Region Neywork «Area

Vasta»

Local

Health

Authority

LHA

Health

Care Area

GPs’

Association

Primary

Healthcare

Centre

«Casa della

Salute»

The Territory from

the region to the

Primary Health care

Centre


Five diseases: diabetes, stroke/TIA, heart failure, hypertension and COPD. We are seriously considering to extend the CCM to the dementia

General Practitioners (GPs) select patients and citizens at high risk. They make their risk or pathology registers

Nurses follow these people through predefined protocols by examination and counselling. For example, for diabetes, glycated haemoglobin, diet, weight control, self-control, physical activity etc.

HOW IT WORKS 1/2


If the patient goes outside protocol predefined limits GP’s visit are scheduled

Obviously there are other professionals such as physiotherapist, dietician, etc. ...

Hospital physician sees patients only if decompensated

HOW IT WORKS 2/2


Chronic Care Model (CCM) – Key Notes

GP select their patients

with the five most

common and important

chronic diseases from

their computer records

of pathology

nurses are in line with

GP’ computers. They

see the GP disease

register, call these

patients in their nurse

offices or follow them

by homecare. They do

to patients tests, visit,

screening, counseling,

etc. ... by predefined

protocols

Patients followed with

CCM avoid

hospitalization and

relapses of chronic

diseases, use less drugs

and diagnostics

Patients who have

disease indicators out

of the protocol back to

visit from their own

GP, because they are

out of balance


From traditional healthcare to proactive healthcare

Traditional healthcare:

The healthcare system acts only when the chronic patient worsens

becoming acute.

Proactive healthcare:

The patient’s needs are taken into account before the disease

worsening and possibly before disease onset, getting better health

conditions for the population, addressing equity issue too.

Chronic diseases are not well

treated and prevention as well as risk factors are not taken

into account. Health inequities are not taken into account

The healthcare system is able to manage chronic diseases and to be effective in facing

the acute diseases onset.

Where Tuscany wants to invest?


WHICH MODEL TO DRIVE THE CHANGE:

THE EXPANDED CHRONIC CARE MODEL (CCM) Expanded Chronic Care Model:

main strategy of the Regional Health Plan

new delivery System design focused on multi-professional care team

new role of nurses in self management support;

decision support through shared clinical pathways;

investment on integrated information system

community resources exploitation

Focus on prevention and health determinants (community oriented primary care)


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concepts of proactive medicine

Health problem When What

Infectious diseases First 60 years of

the '900

Vaccinations

Cancer The last 40 years

of the '900 Screening

Chronic

epidemic End 900 -

beginning of

this century

Chronic

care model


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GPS AND OTHER HEALTH PROFESSIONALS OPERATORS

(NURSES, MEDICAL ASSISTANT …) ORGANIZED IN PRACTICE (6-15 GPS) TO CARE FOR CHRONIC PATIENTS WITH A PROACTIVE APPROACH (CHRONIC CARE MODEL)

Pilot phase

June 2010

11 LHAs

• 56 practice

• 497 GPs

•112 Nurses

• 618.969 Patients

Extention phase

March 2011

Other groups are expected to be involved

• 31 practice

• 301 GPs

• 62 Nurses

• 337.213 Patients


Per-capita spending of diabetic visit 2010

2,0

3,0

4,0

5,0

6,0

7,0

8,0

2009 2010

CCM NO - CCM

Francesconi P., Tuscan Health Agency


HbA1c

40

50

60

70

80

90

100

2009 2010

%

Deprived

Not deprived

Lipids

20

30

40

50

60

70

80

90

100

2009 2010

%

Deprived

Not deprived

Impact on inequalities

Francesconi P., Tuscan Health Agency


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Inpatients hospital admission rate


People are very happy for this model. They really like it

reduce hospital admissions for the five diseases and their costs

reduce hospital visits for these diseases and waiting lists

reduce the gap between rich and poor people in using health services

SOME RESULTS ½ STRENGTHS


The model is running almost half of Tuscan Population, but we will improve it

The number of visits in our Primary Health Centres is increasing, of course

We need a robust ICT net (information system, tele-health, broadband…) to continue to implement this model. Now we have only partially.

SOME RESULTS 2/2 WEAKNESSES


Primary Healthcare Centres

Health clinics

Health Houses

Case della salute

This is a building where work together

• GPs

• nurses,

• administrative personnal,

• social workers,

• social health personnel,

• doctor specialists

• etc.,

It is always open h24, 7/7


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Castiglion Fiorentino

Casa della Salute – 2004 Massa

Carrara

Livorno

Florence

Grosseto

Siena

Pisa

Arezzo


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Quarrata


Case della Salute – 2007 Massa

Carrara

Livorno

Florence

Grosseto

Siena

Pisa

Arezzo

Empoli Terricciola


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Marlia

Piazza al Serchio

Viareggio

Agliana

Campi Bisenzio

Lamporecchio (*)

Colline Medicee

Scandicci


Case della Salute - 2010 Massa

Carrara

Livorno

Florence

Grosseto

Siena

Pisa

Arezzo

Quarrata

Val di Bisenzio

Montemurlo

Empoli

Quarrata

Terricciola


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Year Are

working

Will

open

In

project

TOTAL

2012 20 20

2013 13 33

2014 17 50

p. salvadori overall presentation of the healthcare system in the region of tuscany

Documents

health director

health organization

tuscan health service

national health service

different health systems

italian regions

chronic diseases

general director