1. Some issues raised by the implementation of integrated care for patients with chronic diseases National Implementation of Innovations in Integrated Care Wednesday April 2nd 2014 Dominique POLTON National Health Insurance, France

2. 1.Organisational models Some issues raised by the implementation of integrated care for patients with chronic diseases Patient-centered, high quality care, coordination of interventions from a wide range of professionals, promotion of active patient engagement 2.Tools 4.Efficiency / financial sustainability Objective 3.Step-by-step approach National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014

3. Organisational models (1/5)  Who is the best care coordinator in different situations ? National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014 GP Role of other PCPs (nurse / pharmacist) Multidisciplinary teams External support & coordination Case managers / facilitators Local networks Public agencies Insurance funds

4. Organisational models (2/5)  Who is the best care coordinator in different situations ? National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014 Role of other PCPs (nurse / pharmacist) Multidisciplinary teams External support & coordination Case managers / facilitators Local networks Public agencies Insurance funds PRADO (orthopaedic surgery, chronic heart failure) GP

5. Organisational models (3/5)  Self management support / patient empowerment National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014 Role of other PCPs (nurse / pharmacist) Multidisciplinary teams External support & coordination Case managers / facilitators Local networks Public agencies Insurance funds Patient Call center Outbound phone calls to medium & high risk patients Feed back to GP relays GP Internet portal Peer support (patients groups organised by the French diabetes association GP

6. Organisational models (4/5)  Adaptation to the evolution of professional practices National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014  Multidisciplinary team in the same premises (medical homes, health care centres) --> therapeutic education, prevention programs,…  GPs and other health care professionals form a team with a project but not in the same premises  New coordinated services without practice redesign --> protocols to ensure homogeneity (i.e. return home program for heart failure patients) Level 1 Level 3 Level 2

7. Organisational models (5/5)  But even with multidisciplinary teams different levels of coordination may be needed for some populations, especially to link the cure and care sectors National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014 PAERPA pilot programs in 9 French regions to improve coordination of care for individuals aged 75 and over with complex needs and at risk in terms of loss of autonomy

8. Tools National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014  Shared information among professionals, but also information on the available resources, information for patients  Personalised care plans – e.g. PAERPA  Design  Compensation (GP + nurse +/- pharmacists)  Training of health professionals  News professions in charge of the coordination for complex cases (which profile ? different situations)

9. Step-by-step approach National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014  Electronic multi-disciplinary patient record  First step = development of electronic medical records in GP practice  Exchange of information & Multidisciplinary patient record  Issue = information sharing between health professionals and social workers  From a disease-oriented approach to a global approach  The disease-oriented approach is considered too narrowly focused and not taking into account multimorbidity,  Yet it may be a pragmatic first step to design a pathway

10. Efficiency/ financial sustainability National Implementation of Innovations in Integrated Care - Wednesday April 2nd 2014  Stratification of patients and adaptation of the level of resources  Example 1 : PAERPA pilots --> care plans for 20% of the population aged 75 and over --> criteria  Example 2 : Case managers : level of workforce needed ?  Example 3 : Therapeutic education programs --> priorities / level of resources devoted  Use of the ICT  Internet portals  Peer support through forums,  Telemedicine…