1. Badalona Serveis Assistencials
The Chronic Care Model in BSA
Jordi Piera
Badalona Serveis Assistencials, Catalonia
Barcelona, 17/06/2015
Badalona Serveis Assistencials

2. Chronic Care Model - Aims
The main objective of the CCM programme is to offer an integral care model through the provision of social and healthcare services, to patients with multiple chronic conditions, based on the optimization and integration of resources to give a fast response to the needs of the inhabitants in the region.
Specific objectives:
Position the patient in the middle of the care model
Plan and realize the interventions focused on identify, prevent and treat in advance the acute episodes to avoid further hospitalizations
Design and realize individual integrated care plans based on the evaluation of each particular need and the integral geriatric evaluation (VGI)
Promote the independent life of those patients as much as possible maintaining good quality of life
Coordinate the work of the interdisciplinary teams doing the interventions
Guarantee and provide a continuum of services
Badalona Serveis Assistencials

3. Catalonia region - Contextualisation
Source: Department de Salut. Generalitat de Catalunya (2012).
Badalona Serveis Assistencials

4. Case management – Integrated care
Case management is the procedure where the nurse coordinates the provision of care to guarantee the accomplishment of needs, through the control of symptoms and the management of the most adequate resources, to empower the autonomy of patients.
Badalona Serveis Assistencials

5. How did we organize it – Integrated care
Nurse leading the coordination
Multidisciplinary teams doing continuous assessment and reassessment of needs
Different pathways / programs have been put in place to tailor them according to the patients needs
Put the patient in the middle of the care process
Engage the family and the community assets within the care process
Continuous evaluation to improve the services provided
Homecare Department to coordinate the provision of services
Badalona Serveis Assistencials

6. Regional case management model
Regional model, no service segmentation.
Integration and regional focus
Predictive stratification tool available regionally-wide
Proactive enrolment of users into the program
Case Managers at every Primary Care Centre and at the Homecare Department
Within the Regional Case Management, GPs keep being responsible of the patients
Continuous evaluation process
Coordination between healthcare levels, social care, third sector providers, external providers, etc.
Badalona Serveis Assistencials

7. Stratification tool
9/19/2018
ACT Programme

8. Stratification tool
9/19/2018
ACT Programme

9. Stratification tool
9/19/2018
ACT Programme

10. Some outcomes from the CCM
Regional Case Management Program:
Characteristics of the patients: 76 years ratio, 52% woman, 1,38% prevalence, 20% with social problems, 67% more than 10 drugs,
Interventions done: 86% VGI, 76% flu vaccine, 85% pneumococcus vaccine, 54% ATDOM program, 78% full assessment program
Results: 12% reduction GP, 8% reduction nurse (PC), 40% reduction emergencies, 56% reduction of non-programed hospital admissions, 23% increased QOL, 89% increased satisfaction with the service, 59% increased death at home
Badalona Serveis Assistencials

11. Badalona Serveis Assistencials
Conclusions
The initial driver of CCM in this case was a policy commitment towards a patient-centric model which would enable the continuum of care at a local level (municipality)
Reorganisational process and the governance mechanism established have been the main drivers of CCM
Health and social care professionals play a leading role in facilitating CCM deployment
Interoperable information systems has fostered the full deployment of CCM
Absence of major conflicts between the distribution of resources and the alignment of incentives
Badalona Serveis Assistencials

12. Badalona Serveis Assistencials
Some highlights – CCM
Achieving a full deployment of CCM programs is a slow process
It’s better to start with health services and then integrating it with the social services
Problems for achieving it are organizational and cultural
Expect huge resistance from professionals
Integrated common care pathways should be developed
A continuous review process should be put in place to keep monitoring and improving the services / programs
IT is a tool that will help you within the process, but not the solution (EMR. SCR, ICR and shared care plan are central)
Proper quality and cost-benefit evaluation needs to be conducted
Badalona Serveis Assistencials

13. Regional Case management - Case manager activities
Activity
Amount
Phone calls
33%
Home visits
24%
Self-management
31%
Primary care visits
10%
Other 2%
Badalona Serveis Assistencials

14. Badalona Serveis Assistencials
Challenges
No alignment between the Catalonian Health Plan and the purchaser of services -> still buying by activity such as discharge
Improve the liaison with health assets available within the Community to deal with the social problems (exclusion and isolation)
The role of the internist
Link with sub-acute units
Badalona Serveis Assistencials

15. Badalona Serveis Assistencials
Thank you!
Jordi Piera Jiménez Director of ICT and R&D&i
-  Cell.: Skype: jpieraj
Badalona Serveis Assistencials