RD 12/0001/0011
Innovation in care for chronic conditions
Valencia Reference site Dr. Bernardo Valdivieso
[email protected]
Proposal......
2
Overview
- Introduction - Good practice - Next steps
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An introduction to the Valencia region
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An introduction to Department LA FE
•
•
Population: 300.000 –
> 65 years old: 17,3%
–
11 Health Areas
Health System –
Hospital for tertiary care: 1
–
Hospital for chronic patients:1
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Primary Care Centers:
• Human resources
•
–
Hospital: 6.800
–
Primary Care: 350
Activity: •
•
35 % basic; 65% reference
Budget: 600 M€
5
Summary
- Introduction - Good practice - Next steps
6
Proposal......
7
Innovation in care for chronic conditions
Principles 1.
Identify and assign risk to chronic population
2.
Adapt service portfolio
3.
Plan and coordinate care across all care resources, using the methodology of case management
4.
Guides and disease-specific protocols
5.
Introduction, promotion and use of ICT
6.
Evaluate and improve quality, cost and service
7.
Align incentives, resources and managing partnerships
8
Innovation in care for chronic conditions
Principles 1.
Identify and assign risk to chronic population
2.
Adapt service portfolio
3.
Plan and coordinate care across all care resources, using the methodology of case management
4.
Guides and disease-specific protocols
5.
Introduction, promotion and use of ICT
6.
Evaluate and improve quality, cost and service
7.
Align incentives, resources and managing partnerships
9
Identify and assign risk to chronic population Case management
Professional Care
Patients who need a intensive level of attention •Highly-complex chronic conditions •End of life conditions
Disease management: Patients with medium level of need • Moderately-complex chronic conditions
Supported self care Patients with low level of need • Low-complex chronic conditions 10
Identify and assign risk to chronic population
Identify and assign risk to chronic population Predictive Model Calculo Modelos 31-12-2008 Pacientes Medida de fiabilidad de modelos
Diagnosticos
Calculo Modelos 31-12-2009
Urgencias 6 meses
Ingresos 6 meses
Pacientes
Consumos Urgencias Consultas 6 meses
2008
Consumos Hospitalización (no programada)
2009
Medida de fiabilidad de modelos
Diagnosticos
2010
2011
Urgencias 6 meses
Ingresos 6 meses Consumos Urgencias Consultas 6 meses
2008
2009
Consumos Hospitalización (no programada)
2010
2011
12
Identify and assign risk to chronic population Hospital La Fe | Per capita stays | Predictive Model
Model capabilities versus total stays 100%
DEPENDENT VARIABLE: unplanned stays. 75%
50%
EXCLUDED: Traffic injuries, Burns, Childbirths
100%
79% 25%
40% 26%
GOAL/TARGET 40% of the STAYS
0% Total stays
Unplanned stays
Unplanned stays
Unplanned stays
Capita >14
Pop. > 14
280..000 100 %
3.000 1,2%
Identify and assign risk to chronic population Hospital La Fe | Per capita stays | Predictive Model
Model capabilities versus total stays 100%
75%
50%
100%
79% 25%
40%
26%
0% Total stays
Unplanned stays
Unplanned stays
Unplanned stays
Capita >14
Pop. > 14
280..000 100 %
3.000 1,2%
Identificación población
Innovation in care for chronic conditions
Principles 1.
Identify and assign risk to chronic population
2.
Adapt service portfolio
3.
Plan and coordinate care across all care resources, using the methodology of case management
4.
Guides and disease-specific protocols
5.
Introduction, promotion and use of ICT
6.
Evaluate and improve quality, cost and service
7.
Align incentives, resources and managing partnerships
19
Adapting care processes. "Case Management" Caregiver
Self- Control
Patient
Inclusión
C. Inclusion
Self-Care
Home Care
IB
