Primary Care role as a key element for an excellent health and social integrated care model Health...

Primary Care role as a key element for an excellent health and social integrated care model

Health and Social Integrated Care

Can we live longer?

Can we live better?


Yes, but with increasing complex needs

UNCERTANLY: It is difficult to predict what the best decision

LACK OF AGREEMENT: experts may not agree on the recommendation

MULTIMORBIDITY: accumulation of problems you have to manage

MULTIPLICITY: many actors involved in the decision making

INSTABILITY: the difficulty of finding an equilibrium state

GRAVITY: intensity that the problem is manifested

PROGRESSION: speed with which the situation can deteriorates

FRAILTY: low personal resilience

IMBALANCE: from an area that can decompensate other

Complex needs...

Have to do with the impact on people live and the difficulty to manage them and often mean:

4

Health and Social Complex needs?

5

An integrated care approach because... Catalonia has a very aged population and it will has an even more aged population.

Aging causes chronic condition, disability and dependency.

There is a group of people, around 8-10%, which presents or may present health and social complex needs concurrently and the cost of their care might represents 50% of the Government budget.

In care giving and social health needs are not easily separable.

Preventive policies are more effective through integrated measures between social care, healthcare and often educational system.

We have a baseline care model that is favorable to the proposed transformation.

There is evidence that integrated care is prioritized and can improve outcomes of care for people with complex needs.

Integrated care is the most efficient, sustainable, and satisfactory to meet people’s needs.

Una mirada internacional a la construcción de sistemas de atención Integrada social y sanitaria

Source: Kodner D. King’s Fund, 2011

Sources: Kodner D, Goodwin N, Thiel V.

King’s Fund, 2013

http://www.local.gov.uk/web/guest/health/-/journal_content/56/10180/4060433/ARTICLE

https://www.gov.uk/government/policies/making-sure-health-and-social-care-services-work-together

http://www.theguardian.com/healthcare-network/2013/sep/18/health-social-care-integration-success

http://www.kingsfund.org.uk/sites/files/kf/dennis-kodner-integrated-care-frail-older-people-kingsfund-sept12.pdf








¿Existe evidencia de éxito en los modelos de atención integrada?



An integrated care approach because...



Social needs...Have to do with the dynamic adjustment between functional and relational integration (Fantova, 2008b).

Functional autonomy needs

Interpersonal and relational needs

Instrumental and material needs

ssb(basic social services)

Front door to entry the

social care system

From the relationship

as main tool

as closer as possible

Community- based and territorial

prevention oriented care

Hospitals

Integrated Care: more than multi-level health care integration

www.flaticon.com (1)www.freepik.com (1) (2) www.morguefile.com

COMMUNITY

HEALTH AND SOCIAL PRIMARY CARE SERVICES

Emergency service

Paliative care

Long term care

Intermediate care

Residential care

Nursing homes

Daily care

Home care

http://www.flaticon.com/

http://www.freepik.com/

http://www.morguefile.com/

Continuity of care

Integrated health and social care: Shared approach

Multiple front door (mainly at the primary care level)

Shared care / case management

Join and comprehensive assessment for health and social needs

Shared proactive action Plan

Monitoring, evaluation and feedback

person-centred

Comprehensive approach

Empowered

users

Shared

information

Professional

leadership

Identification and registering (in the community)

Community based care

Implementing community-based integrated care in practice

Towards a collaborative model of integrated care in Tona

Ámbito territorialÁmbito territorial

Geo

grap

hica

l sc

ope Tona (Phase 1)

• Local Community with 8,085 inhabitants (15,75% aging tax)

Mancomunitat La Plana (Phase 2)• Voluntary Local Government Association of 12 localities with

32.000 inhabitants

Muntanyola

Folgueroles

Malla

Taradell

Balenyà

Tona

Seva

Viladrau

El Brull

Aiguafreda

St. Martíde Centelles

Sta.Eulàlia de Riuprimer

Seva

Muntanyola

Mancomunitat la Plana:Population: 31.924 hab. Density: 92 km2Municipalities: 12

Población diana

Fuente: morguefile.com

Targ

et p

opul

ation

(Pha

se 1

) Elderly who can take part in the active aging and health promotion program of Tona: 1308 people

Frailty and Dependency condition people in Tona: 480 people

Chronic condition patients in Tona: 149 (PCC - 87 / MACA - 62)

Visión agentes y finalidad

Visi

on Prevention

Continuous Care

Integrated Care and Person-Centred Attention

Professional and team leadership

Community approach

Stak

ehol

ders

Basic Social Service Team and active aging program

Specialized dependency services: telecare, home care service, support and accessibility products bank

Primary Health Care Centre

3 elderly home services

The collaborative model for addressing the health and social care in the town TonaIntegrated care for our

target (Phase 1: Chronic cond. dependency, complexity).

Multiple gateways but shared answer

Creating a local dependency commission

Making sure a shared access to data in both

systems.

Main activities:

6 plenary sessions of the leader team (2013)

9 sessions of the dependency commission (2013)

Identification of a potentially combined population of

629 people (fragility / dependency / pcc + maca) including:

36 pcc / maca known by the basic Soc. Services 183 with tla / 19 home care (528.75 hours)

Access to the Local Dependency ICT System for the health social worker

The collaborative model for addressing the health and social care in the town Tona

Improved care at the care home level

Processes, routes and work tools redesign for a better planning of personal care

Telecare, homecare & accessibility products;

transitional home care, optimization

Main activities:

36 intervention plans adopted jointly (2013)

11 transitional home care services activations before discharge (2013)

31 joined assessment for the accessibility products bank and technical aids (2013)

1 Study at the County Leven about the Quality of the Home Care Service (in process)

1 Pilot Project about telecare service outside home (just started)


Joined “Promotion and Prevention Action Plan for Active Aging and Health Promotion”

Creating a committee for the promotion of health and active aging

make sure the participation of all the stakeholders (including the residential services,

in the community)

Main activities:

5 sessions of the active aging commission

28 activities promoting health and active aging

632 participants (from 1308 potential participants)

201 hours of activity to promote health and active aging (4772 hours of impact on the overall beneficiary)

15 professionals involved


Integration of residential services as stakeholders of the model:

Primary health service established

an agreements between the 3 homes services

Point of health record and medical services from the

primary health center. Pharmacy decrease

Main activities:

3 cooperation agreements signed with residential services in the municipality.

14% of reduction of users who have been hospitalized during the year (from 31& (2011) to 17% (2013)) and pass from 724 (2011) to 187 (2013) days staying at hospital

29% of reduction in hospital or nurse home deaths (from 54% (2011) to 25% (2013))

Reduced on pharmacy spending (2008 - 2013): Obra de Maria: 53% Prat: 11.93%

Shared training activitiesCooperation and integration initiatives within a wider geographical scope institutions

Font: morguefile.com

We must ensure that people can

# Be, feel and live well despite the personal situation; # Have a diagnosis, a unique and shared definition of personal needs;

# Receive appropriate support where and when needed;

# Know how and how to contact when you need professional help;

# Be informed of everything that affects my process;

# To be consulted and respected in all decisions that affect me

In short, to live and die well..

Discussionhow to define and promote collaborative environments with the workforce from all the services involved as a continued learning process?

how we promote a new role from the citizens as active partners to this changing model of care?

what do the primary health care expect from the primary social care sector and how it fits with the social care sector mission?

which should be the common goals in this new scenario in order to move further into the bottom-up model.

gencat.cat

El sistema Català de Serveis Socials Principis orientadorsUniversalitat i equitat

Cartera de Serveis Socials:•Prestacions de servei

•Prestacions econòmiques

•Prestacions tecnològiques

La Xarxa Pública de Serveis Socials“conjunt de recursos, prestacions, activitats, programes, projectes i equipaments destinats a l’atenció social de titularitat de qualsevol de les administracions públiques o concertades per aquestes amb la iniciativa social o privada” (art. 14)

Ordena l’estructura en forma de xarxa i en base a dos nivells:

• Serveis socials bàsics: Ajuntaments i governs locals

• Serveis socials especialitzats: supramunicipals o govern autonòmic

El rol del tercer sector:• La llei defineix el rol del tercer sector i la provisió privada de serveis

Els professionals del sistema:•Formació, seguretat en el treball, reconeixement social de la funció, coneixement I competència.

Finançament del sistema:• Incorpora formalment la participació de l’usuari.

•Una part important queda subjecte a desplegament normatiu

Pla estratègic de serveis socials i Pla de Qualitat:•Prorrogats

•Existència de Plans sectorials i PALMSS

Existència de normativa sectorial•Llei dels Drets i Oportunitats de la infància i adolescència

•Llei d’eradicació de la violència masclista

•Llei de prestacions econòmiques

•Llei d’acollida de persones nouvingudes

24

Planning and Commissioning

Local Government

3rth Sector Entities and

Private providers

Catalan Government

The stakeholders

The network

The basis

The Basic Social Services Areas

The specialized social services The 3rth Sector Activity

Public Social Service Network (Resources, benefits, activities, programmes, projects and facilities

Publicly- and privately-operated

Catalan System of Social Services

Catalan Model of Integrated Health and Social Care (PIAISS)

punto DE PARTIDA DE LOS MODELOS COLABORATIVOS

Department of Health

Department of Social Welfare and Family

Program of Prevention and Attention to Chronic Condition

Starting point:

3 September 2013:Government Agreement where is expected to

develop a new Integrated Health and Social Care Plan in Catalonia

3 December 2013: Government Agreement for the shared IT

strategy

25 February 2014: New Government Agreement for the creation

of the PIAISS

Inter-ministerial Social and Health Care and Interaction Plan

MISSION

29

Promote and participate in the transformation of the health and social care model with the aim of ensuring an integrated and people-based care that responds to their needs.

30

Inter-ministerial Social and Health Care and Interaction Plan

Promoted by the Government of Catalonia 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.


31

Catalonia has a very aged population and it will has an even more aged population. Aging causes chronic condition, disability and dependency.

There is a group of people, around 8-10%, which presents or may present health and social complex needs concurrently and the cost of their care might represents 50% of the Government budget.

In care giving health and social needs are not easily separable.

Preventive policies are more effective through integrated measures between social care, healthcare and often educational system or other policies.

We have a baseline care model that is favorable to the proposed transformation.

There is evidence that integrated care can improve outcomes of care for people with complex needs.

Integrated care is the most efficient, sustainable, and satisfactory to deal with people needs.

Una mirada internacional a la construcción de sistemas de atención Integrada social y sanitaria


Sources: Kodner D, Goodwin N, Thiel V.

King’s Fund, 2013












¿Existe evidencia de éxito en los modelos de atención integrada?






Can we live longer?

Can we live better?


Yes, but with increasing complex needs

UNCERTANLY: It is difficult to predict what the best decision

LACK OF AGREEMENT: experts may not agree on the recommendation

MULTIMORBIDITY: accumulation of problems you have to manage

MULTIPLICITY: many actors involved in the decision making

INSTABILITY: the difficulty of finding an equilibrium state

GRAVITY: intensity that the problem is manifested

PROGRESSION: speed with which the situation can deteriorates

FRAILTY: low personal resilience

IMBALANCE: from an area that can decompensate other

Complex needs...

Have to do with the impact on people live and the difficulty to manage them and often mean:

Health and Social Complex needs?

36

3 conditions to define the complexity

1Specific

profile of needs

2Accountable professional

criterion

3Benefit

enabled by the identification

Continuity of care

Integrated health and social care: Shared approach

Multiple front door (mainly at the primary care level)

Implementation (efectivity, eficency, coordination, multidisciplinarity)

Join and comprehensive assessment for health and social needs

Shared proactive action Plan

Monitoring, evaluation and feedback

person-centred

Empowered

users

Shared

information

Professional

leadership

Identification and registering (in the community)

Community based care

Case managem

ent / Shared care

Comprehensive approach

Hospitals

Integrated Care: more than multi-level health care integration

www.flaticon.com (1)www.freepik.com (1) (2) www.morguefile.com

COMMUNITY

HEALTH AND SOCIAL PRIMARY CARE SERVICES

Emergency service

Paliative care

Long term care

Intermediate care

Residential care

Nursing homes

Daily care

Home care

http://www.flaticon.com/

http://www.freepik.com/

http://www.morguefile.com/

The vision: the key elements of the Integrated Care Plan:

40

Integrated health and social care model covering all population actions throughout the life of the person with the leadership of health and social primary care and local partnerships agreed plans.

Person– centered and comprehensive care focused on the needs of individuals through joined case / care load, assessment and action plan

Community-based care as closer as possible to the place of residence of the individual. Increasing home and community care and defining local care pathways.

Continuity of care, regardless of entry in the systems.

Strong involvement of clinical and professional leadership so then athrough a new professional culture with planned and proactive collaboration is needed.

Empowered patients with a new relationship with services. Self-care improvement

Quality and secure shared information systems.

Shared Integrated Care Outcome Framework. Triple Aim orientation.

Promotion of bottom up experiences based in PAISS values and principles

Use of resources through a shared and unique vision.

Streamlining of resources having the poorest cost-effectiveness and use of stratification methods including social data

Catalan Model of Health and Social Integrated Care. Core & enabling elements

“Microsystems”• Community-based and

primary care leadership • Integrated care pathways• Multiprofessional work• Transitional care • Out of hours care• Home care strategies

Joint case / care load. Shared needs assessment + action plan

Stratification models: assessing population needs

Clinical and professional leadership

Health and social care local Partnerships

Shared outcome framework : shared responsibility & joined accountability

Shared vision about the use of resources: Aligned Incentives

Shared Electronic Health and Social record

Person Empowerment and Self-care

ENABLING ELEMENTS

Multi-lever approach: ALL things at the same time

Culture and change management

PIAISS strategic lines

42

Community-based integrated care, i. e. primary social and health care

Health and Social home care model

Adaptation and organization of long-term health and social care and intermediate care for mental health condition

Model of health and social care in the residential / nursing home

Interaction between the health and social care areas of the mental health and drug addiction and HIV/AIDS network

Improvement of the dependent care system

PIASS strategic lines

43

Integrated information systems

Collaborative and relational ecosystem

Sustainability and stability

Population-based outcome framework. Triple Aim oriented

Integrated care as an innovative practice

DiscussionDoes a continuous dialogue between health and social exist?

How to manage this cultural change from both sectors and promote collaborative environments with the workforce? Who and how should act as assembler of the process?

What do the primary health care expect from the primary social care sector and how it fits with the social care sector mission? Which should be the common goals in this new scenario in order to move further into the bottom-up model?

Which data is primary health care interested on from the social primary care and which is willing to share?

Could we define shared strategies from de primary level in terms of virtual model of care?

Do primary care consider social care alternatives when planning how to attend chronic condition patients?

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