MECASS Project ICS pilot for chronic desease IBM Corporation

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Juan Antonio Juárez Ojeda
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1 MECASS Project ICS pilot for chronic desease

2 Agenda Healthcare industry environment MECASS project objectives MECASS Solution Project Plan pilot Solution Demo Next Stepts 2

3 1. Health care industry environment The healthcare system needs a completely transformation to meet the new challenges at different levels social, IT and economical Budget reduction + Increase chronicity Guarantee the quality + of the service = Challenge: manage efficiently the resources assined to chronic patients crónico Current environment Systems oriented to the medical act. Low personalization of complex cases Low consensus level of agreement in the patient treatment High traditional units activity: A&E Reactive system Difficulties for the treatment adherence Low integration with palliatives units No patient centric vision Process & Organization Systems oriented to treat the pathology not the patient (clinical pathways, processes ) No case management role extended No transversal care plan treatment Low culture of homecare Low telemedicine processes No alternative units for A&E treatments. No integration with social services No integration with intermediate care attention IT Systems with low level of integration No 360 vision of patient No proactive systems for given support to the professionals. No clinical pathways implemented in all healthcare levels (partial implementation). Difficulties to measure the KPIs No mobiles development solutions 3

Low personalization of complex cases Low consensus level of agreement in the patient treatment High traditional units activity: A&E Reactive system Difficulties for the treatment adherence Low

1. Health care industry environment - Catsalut Strategy 2011-2015 Objectives set by 2015 Implement clinical practice guidelines and treatment routes in the ten processes throughout the region, and to

4 1. Health care industry environment - Catsalut Strategy Objectives set by 2015 Implement clinical practice guidelines and treatment routes in the ten processes throughout the region, and to integrate them into the HCCC registers. Implement 5 priority programmes for health promotion and disease prevention (healthy eating and physical activity, smoking, alcohol consumption, vaccination and infant or prenatal stages). Extend the Pacient Expert Catalunya programme to cover five chronic diseases throughout Catalonia, with a figure of 5,000 patients incorporated into the different disease groups; Reduce the number of emergency hospital admissions and readmissions within thirty days for complex chronic patients at acute care hospitals by 15%. Have a case management model for complex chronic patients in all regions and defined treatment routes, covering 25,000 complex chronic patients. Revise and reconcile 100% of pharmacological treatments, including all the healthcare areas and guaranteeing quality, facilitating access and improving treatment adherence. 4

Implement 5 priority programmes for health promotion and disease prevention (healthy eating and physical activity, smoking, alcohol consumption, vaccination and infant or prenatal stages).

5 2. MECASS Objectives Chronic disease Solution Project objectives: define a solution to cover chronic disease management (functional + technical) Define a common functioning model for chronic disease patients, functional (e.g.: clinical pathways) and technical (e.g.: IT to support the process) Select a pilot for the deployment of the new model (target territories, type of patient, etc) Put in place the IT tools that will allow to: Create a holistic vision of the patient through all the healthcare organizations (acute, primary and chronic) implement a case management tool that supports the model include interoperability and analytics capabilities into the solution landscape design and implement a tool to interact with the citizen Characteristics: Patients: Chronic patients in the region: ~ 2,1 M inhabitants (of which 2,5% are very complex). Government minimum strategic commitment: enrolment of patients (very complex profile) by the end of 2015 Pilot: 150 patients / 2 regions (MS and MN) / 6 Case Managers 5

: clinical pathways) and technical (e.g.

6 2. MECASS Objectives model assumptions ORIENTATION TO TRANSVERSAL PROCESSES Implementar la gestión por procesos en la asistencia (programas de salud). Integrar los procesos a todos los niveles asistenciales de forma transversal (guías clínicas y rutas). Fomentar la práctica orientada hacia los resultados. INFORMATION IN REAL TIME TO ALL ACTORS INVOLVED Incrementar la seguridad de los datos. Asegurar flujos de información integrados en todas las derivaciones (origen destino). Abrir el sistema a todos los proveedores de salud de la red. Proporcionar una visión integrada del paciente: 360º. PRO ACTIVE SYSTEM ALERTS Reducir los tiempos de diagnóstico mediante el soporte a la decisión. Interpretar los resultados en tiempo real: gestión de avisos y alertas clínicas. Dotar de capacidad para analizar de modo on-line los eventos relacionados con el paciente (ingresos, altas, exacerbaciones, adherencia, etc.). Identificación de patrones de comportamiento. 6 KPIS MEASUREMENT Lograr la optimización de los procesos. Permitir la monitorización constante de los procesos. Medir en todo momento el éxito de los programas de atención mediante los KPIs acordados. Lograr la máxima transparencia de resultados y la provisión de información a todas las organizaciones involucradas.

INFORMATION IN REAL TIME TO ALL ACTORS INVOLVED Incrementar la seguridad de los datos. Asegurar flujos de información integrados en todas las derivaciones (origen destino).

7 Sistemes de proveidors Sistemes comuns 3. MECASS Solution The proposed new technological components to respond to new challenges are summarized below: 7

4. Project Plan strategy enrollment Helath care catalan Goverment strategy for 2015: to enroll 25.

8 4. Project Plan strategy enrollment Helath care catalan Goverment strategy for 2015: to enroll complex patients Pilot phase Mar 2013: 150 patients enrolled into case management solution (Cúram) Phase 1 Dec 2013: deploy solution for 2 regions (4.000 patients enrolled) Phase 2 Dec 2015: deploy solution for all Country ( patients enrolled) 8

000 complex patients Pilot phase Mar 2013: 150 patients enrolled into case management

9 5. Project Plan Current status Cronicity model definition PoC based on Cúram ICS PoC validation Pilot development Pilot Go Live Clinical pathway for PCC ICS Chronic model based on Outcome Plan 360 vison of patient Cúram user cases for case manager. PoC Customer validation Outcome Plan for complex Chronic diseae patient MDT 150 patients 2 regions of Catalonia 6 case managers Basic Integrations with backend systems Nov 12 Dec 12 Jan 13 Mar 13 KPIs Measurement Project Selling KPIs measurement of Pilot sucess. Sell the project Start the project. Apr 13 May 13 9

PoC Customer validation Outcome Plan for complex Chronic diseae patient MDT 150 patients 2 regions of Catalonia 6 case managers Basic

10 5. Project Plan Common model defined Complex Patients 10

11 6. Solution for case management Holistic vision of patient (360 vision) Heatlh care programs Patient complex Patient Palliative. Clinical workstation Case Manager 11

12 6. Solution for case management Collaborative environment Assig multiple professionals to the patient care Open discussion Agenda of MDT meetings Meeting minutes & agreements 12

13 KPIs 7. Pilot results KPIs Chronic disease model RESOURCES: Reduce the number of A&E cases and inpatient cases for PCC Reduce the number of primary care visits. Reduce the costs of medication plan SERVICE QA: Increase home attention (case manager) 24X7 follow-up patient. Holistic vision of patient (360) CHANGE MANAGEMENT Case manager regional level (SAP level) Create MDT assigned to a patient Create Functional Units to treat complex cases 13

Reduce the number of primary care visits.

14 SYSTEM DEMO 14

15 MECASS Project ICS pilot for chronic desease

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