Integrated care pathway for multimorbid patients

Transcripción

1 Transferability Event Odense, 10 October 2017 Integrated care pathway for multimorbid patients Kronikgune, Research Centre on Chronicity is funded by the European Union, in the framework of the Health Programme under grant agreement

2 Outline Objective Methodology Pathway definition Key elements

3 Objective UP-SCALING the integrated care pathway for frail elderly patients in the 13 Integrated Care Organizations

4 Collaborative methodology: staff engagement and change management 1. Create a multidisciplinary team representing all sectors and organisations who will define the integrated care pathway. 2. Develop, validate and deploy an integrated care pathway for multimorbid patients for all organisations

5 Multidisciplinary team Around 30 professionals: Directors Medical directors Nursing directors Directors of healthcare integration Heads of internal medicine service Reference internists Hospital nurses Hospital liason nurses Primary Care case managers Representatives of Central Healthcare Directorate ehealth Centre responsible

6 What do we mean by Pathway? Methodology for the mutual decision making and organization of care for a well-defined group of patients during a well-defined period. Characteristics: Goals and key elements of care based on evidence, best practice and patient expectations Facilitation of the communication, coordination of roles, and sequencing the activities of the multidisciplinary care team, patients and their relatives Documentation, monitoring, and evaluation of variances and outcomes Identification of the appropriate resources Source: European Pathway Association

7 Target population Case management Disease management Disease selfmanagement Population without chronic diseases Charateristics: with multiple chronic diseases who have complex health care needs; might be at high risk of hospital or care home admission might require a range of high-level interventions

8 What do we have now? Coordination roles Communication tools Appropriate resources Mutual decision making

9 What do we miss now? Well defined group Clear goals Evaluation methods (Some) Resources Sequencing activities of all stakeholders (Some) Decision making

10 Reference care pathway: Carewell

11 Primaria Primaria Internista Internista Validación clínica Estabilizacion Intervenciones Contacto con Medico de Validación integral Valoración atención Estabilización Atención Primaria Plan terapeutico en domicilio Coordinación Centro Salud Centro Salud Primaria hospital hospitalario Programa Kronik-ON social programacion de Llamada mensual Cita presencial trimestral Centro salud seguimiento Cita presencial con AP Primaria/Consejo sanitario Centro Salud Analysis of existing pathways Reference pathway: who, what, how, when, where Comparison between existing pathways in Osakidetza 1. Paciente estable 2. Paciente inestable en domicilio 3. Paciente hospitalizado 4. Al Alta Que hace? Revisión de historia Que hace? Valoración clinica Que hace? Valoración tratamiento Que hace? Informe de Alta Dónde? Domicilio Dónde? Domicilio Dónde? Hospital Dónde? Hospital Quién? Enfermera Atención Quién? Quién? Enfermera de enlace Quién? Enfermera de enlace Que hace? Cita presencial con tests Que hace? Que hace? Valoración integración Que hace? Valoración y Dónde? Domicilio Dónde? Dónde? Dónde? Quién? Quién? Quién? Quién? Enfermera Atención Que hace? Que hace? Que hace? Que hace? Llamada 24/78h Dónde? Dónde? Dónde? Dónde? Domicilio

12 Sequencing of activities Analysis of similarities and differences Reaching consensus among all stakeholders 1. Paciente estable Carewell OSI Araba OSI Bilbao-Basurto OSI EEC OSI Goerri Alto Urola Médico Atención Equipo Atención Primaria Equipo Atención Primaria Equipo Atención Primaria Quién? Primaria Revisión de historia No hay revisión proactiva de historia Qué hace? Validación clínica Valoración integral Plan terapéutico Domicilio Dónde? Centro Salud Carewell OSI Alto Deba OSI Araba OSI Goerri Alto Urola Enfermera Atención Quién? Primaria Cita presencial con tests, No escalas etc Programa Kronik-ON No No Implementación en progreso Llamada de seguimiento mensual Qué hace? Cita presencial trimestral Domicilio Dónde? Centro salud No Cita no específica como paciente pluripatológico pero se realizan visitas en el centro trimestralmente por cualquiera de las patologías No Valoración social Business Process Model Notation

13 Stages Time

14 Key elements The multidisciplinary team included all stakeholders involved in the provision of care for multimorbid patients. All stakeholders believed that defining a common care pathway was a priority from both system s and patients perspectives. The comparison between existing pathways helped to understand that similarities were numerous and diversities were not significant. Building collaboratively a core scheme allowed each organization to feel represented.

15 Thank you