Catalonia has good health care coverage of proven quality and recognised for its results and the satisfaction of the community that uses these services. However, World Health Organization indications, the current economic downturn and population forecasts that anticipate significant ageing of the population in the coming decades, suggest that the available care models should be reviewed to make the necessary changes, and respond correctly to the challenges of the new social, economic and demographic scenario.
In Catalonia we are facing new challenges with an in-depth population ageing process compared with other European countries. In 2050, over 30% and 12% of the population will be over 65 and 80 years old, respectively. As a consequence, an increasing number of people with chronic conditions will increase very intensively. Currently, 17% and 4.4% of the population are over 65 and 80 years old, respectively .
In the past, Catalonia has developed a very good network of primary care centres and long-term care facilities providing very good care in the community as an alternative to hospital care. The split between commissioning and provision role has been incorporated, establishing new contracts and a new commissioning process incorporating cross-cutting targets related to different providers (primary, hospital, mental health and long-term care facilities). However the task to remove organisational silos is a difficult work to perform. More emphasis on integrated care is great opportunity to improve performance.
Within this context, the Ministry of Health of the Government of Catalonia created a Chronicity Prevention and Care Programme at the end of 2011 with an integrated care vision within the new Health Plan, under Government management, explicitly entrusted by legislators to develop this programme and make it operational, in conjunction with the Ministry of Social Welfare and Family. This document is thus the result of a joint effort and the expression of the will to develop it jointly.
Chronicity is a challenge to all developed countries, so the Chronicity Prevention and Care Programme has collected experiences from other geographical areas in our region and adapted them to our local realities. This Programme is set in the framework of the strategic projects and the Health Plan for Catalonia 2011–2015, which makes chronic conditions care a cornerstone of the health system over the coming years and the main driver to achieve integrated care.
It is very important to emphasise the major opportunity from the launching of the new Health Plan for Catalonia 2011–2015 where a new transforming health plan is set out, which aims to attain better results for the Catalan population.
Earlier health plans basically were a large collection of national health targets to be achieved in the next 5-year period. However, the Health Plan for the period 2011–2015 describes expected changes and transformations which adapt the model to the forthcoming challenges in future years. It has been very important to integrate our new Chronicity Prevention and Care Programme into the new Health Plan, being a real Strategic Plan, for the next few years.
The literature review contributes very good examples of transformation such as Kaiser Permanente, the Veterans Health Administration, and high performing regional experiences like the Strategy to Tackle the Challenge of Chronicity in the Basque Country have been very inspiring models to extract and adapt some key features [2–7].
Some interesting key drivers have been identified as high inspiring points to be incorporated in our model: chronic and integrated care policy-driven orientation, introduction of stratification, commitment of clinical leadership involved in design and implementation of local integrated care pathways (ICPs), shared ICT between clinicians and between patients and professionals, overcome of financial barriers introducing new joint cross-cutting targets among primary and secondary care, community care orientation promoting more care at home avoiding unnecessary emergency admissions and institutionalisations and self-management policies.
In addition, the Spanish Ministry of Health has drawn up a national chronic care strategy published 1 year ago with some common principles and aims although the Catalan Ministry of Health has decentralised and total competences to prepare and implement its own chronic care programme .
The Health Plan for Catalonia is one of the most important instruments prepared by the Government of Catalonia. It has 32 strategic projects, 6 of which are related to the Chronicity Prevention and Care Programme. This new Health Plan introduces the following areas of work (Figure 1).
An ‘integrated care’ vision within the health sector but also including an initial collaborative work with social services. Chronic care is expected to be a driver to promote an integrated health delivery approach.
New contractual and financial scheme to incentivise integrated care incorporating some cross-cutting targets related to all providers performance. All agencies are called to contribute to joint targets.
A more interactive and inter-operative global health information system (HIS) through the Shared electronic Health Record of Catalonia (eHR) and the Personal Health Channel (‘Canal Personal Salut’), which facilitates remote care and direct access by patients and citizens. Commissioning authorities are urging all providers to publish a minimum data set of information and reports like hospital discharge report, structured diagnosis generated, structured clinical variables.
Population stratification using clinical risk groups (CRGs) by 3M enterprise to support clinicians to identify people who could be at risk of hospitalisation, readmission or death. Analytical Services at the Catalan Ministry of Health is providing stratification for all providers and it is published in the eHR to be shared by all clinicians. Now this Analytical Services is developing home own made stratification model.
Some information system tools have been introduced to monitor indicators related to this Programme, especially avoidable emergency admissions related to ambulatory care sensitive conditions (ACSC), based on American Healthcare Research and Quality Agency (AHRQ), 30-day readmissions related to the main chronic conditions, updated monthly and accessible to providers and observed chronic conditions prevalence identified by providers.
In addition, the Chronicity Prevention and Care Programme sets out different actions for an increasing number of populations with concurrent health and social needs, especially complex chronic patients (CCP) with multimorbidity or advanced chronic disease (ACD) with social needs or dependence.
Developing comprehensive clinical processes redesign for the chronic conditions with the greatest impact in all areas by building ICPs in each geographical area which comprises a hospital, primary care centres, nursing home facilities and a mental health network. Clinical leaders are called by commissioning authorities to be incorporated in this process of generating local agreements regarding singular provision in each area. It is a joint work performed by health authorities and clinicians belonging to different sectors. Therefore, ICPs based on local clinical facilitate real implementation.
Strengthening health protection, promotion and prevention as instruments for maintaining health and preventing chronic disease . In addition, a new strategy called PINSAP has been launched where key elements of public health are being introduced in cross-cutting governmental policies established by other ministries such as the ministries of Education, Social Welfare and Family, and others.
Promoting the self-care and personal responsibility of citizens concerning their health, risk factors or diseases. The successful Expert Patient Programme Catalonia (EPP) has been implemented with over 4000 patients included in the Programme to date. This Programme comprises an structured methodology where “experts and trained patients” coach and lead equals and comprises different chronic diseases such as diabetes, COPD, heart failure, dementia carers.
Deploying social services and health care facilities working in a more integrated care approach, and adequate comprehensive systems for providing care for chronic and dependent patients. As a consequence, it has been launched a new integrated health and social care plan in Catalonia since March 2014 where it is expected real integrated care between health and social services. The chronic care approach requires an updated vision incorporating social care contribution to achieve better care for people with complex health and social care needs. This new Plan has created great expectation to overcome some of the barriers we have identified in the Chronicity Prevention and Care Programme.
Providing comprehensive and proactive care of patients with complex chronic disease and ACD that ensures a 24/7 coverage model with a good response to potential exacerbations of this patient group. Most ICPs are well designed in a day care approach but they fail during nights and weekend time. Therefore we have reinforce and commissioned each territory agree and incorporated in the pathway, written statements about how to guarantee a quick response in case of acute exacerbation. Different practical actions have been covered including this 24/7 guarantee.
Rationalising the use of medications, especially with people with polypharmacy and improvement of adherence in chronic patients. This is an area where pharmacists have been involved in the construction of a better ‘complex care model’.
Promoting an alternative remote care model substituting face-to-face visits with virtual contacts like telephone and electronic messaging. Citizens have been invited to access to a National Personal Health Folder through ‘robust password’ instead of ‘digital certificate’. Since September 2014 the Catalan Ministry of Health is promoting this strategy to involve an increasing number of citizens and patients.
Replacing acute conventional hospitalisations with other alternatives: sub-acute facilities, day care facilities, a more proactive home care programme in primary health care. It is expected a number of acute hospital emergency admissions could be substituted by these friendlier and more cost-effective alternatives.
In this context, health and social services face the challenge of transforming the current health care model, adapting it to meet the needs of citizens and doing so in a way that is sustainable for the system. It should be kept in mind that many clinical conditions that lead to situations of chronicity and dependence can be prevented or delayed, thus delaying disability for later stages of life or, in other words, increasing a person's disability-free life.
The new Interministerial Social and Health Care and Interaction Plan (PIAISS) introduce real integrated care approach to overcome this challenging issue and develop a real ‘person-centred care model’.
Transforming the model involves not only improving the skills of the professionals and all workforce involved in care processes, but also redesigning how services are provided and encouraging cooperation between health care and social service sectors, and between organisations and professionals working for the same patients.
In addition, some new financial and contract scheme has been introduced in 2014 to modify and transform the current health provision. Common and cross-cutting targets and indicators such as the following are being introduced. It is expected that professionals working at different areas (primary care, hospital, mental health and long-term care facilities) have a shared outcome framework as an important driver which facilitates and reorient their performance . Here there is a description of these targets which have been incorporated in all contracts:
It is expected to introduce a new triple-aim approach to the contract as a ‘powerful integrator driver’ in the next years. There are no measures related to ‘experience of care’ domain .
Two years after the implementation, it has been achieved some initial results which encourage reinforcing this strategy and new key actions are being incorporated to strengthen this journey towards more integrated care progress.
It could be reported some progress in the following areas:
A conceptual and methodological framework with a related implementation-oriented checklist has been used on a local level to design and later implement these pathways. This action is perhaps the most important strategy to achieve ‘bottom-up’ change and transformation. Managers and clinical leaders wanted to have available practical guidelines to support implementation process.
Over 80% of ‘natural territories’ or ‘microsystems’ have drawn up and implemented, at least in a preliminary way, the ICPs related to four clinical conditions: diabetes mellitus, heart failure, COPD and depression. All territories have ICPs for three clinical conditions. We consider a ‘microsystem’ as a territory or geographical area where most chronic patients use services required by them. In general terms, this includes a hospital with secondary care services, primary care teams operating collaboratively with the hospital, a nursing home and mental health and social care.
New ICPs will be designed and implemented related to additional clinical conditions: dementia, chronic kidney disease, chronic osteoarticular pathology and chronic pain.
In the case of heart failure and COPD, there is a reduction of 37% and 42% of emergency hospital admissions, respectively.
Next steps in the Programme will be the elaboration of two new forthcoming guides in depression and obesity, and a new project called ‘Expert Carer Programme Catalonia’ related to four areas of caring support: children with chronic diseases, patients with dementia, CCP and patients with a severe mental disorder.
Another work area is the improvement of ‘health literacy’. There has been incorporated into the Health Survey for Catalonia (HSC) administered twice a year to 3000 Catalan citizens, questions related to health literacy. During 2014 the HCS included a specific module version in Catalan and Spanish, the short version of the European Health Literacy Survey Questionnaire (HLS-EU-Q16). This 16-item questionnaire is an abbreviated version of questionnaire HLS-EU-Q47 drawn up by the HLS European Health Literacy project 2009–2012 . We could assess the current ‘health literacy’ situation in the future and progression over the next few years.
This implies a very challenging area of work because of the greater needs of patients with these conditions; a model has been created on a local level more oriented to coping with the enhanced needs and demands generated by frequent acute exacerbations and intensive use of services (Figure 4) [2, 15, 16].
However, this change and transformation requires time; the following initial results and milestones related to implementation of this project can be identified:
Guidelines that determine the implementation of a cross-cutting programme of rational use of medicines and incorporate support tools for a more appropriate prescription have been designed.
There is an emphasis on improvement in the regular and systematic review/conciliation and adherence with the chronic medication and, in particular, in complex patients.
Some important achievements have been made:
One of the most important features of the Chronicity Prevention and Care Programme in Catalonia has been to incorporate a strong emphasis on health promotion and disease prevention. This could be described as the most important development in this area :
In general terms, the Chronicity Prevention and Care Programme set up by the Health Plan for Catalonia 2011–2015 have contributed to create better conditions to achieve better outcomes for chronic patients. It has been observed some better figures related to a range of outcomes established at the end of 2011. In addition to these results, it should be recognised an important progress to redesign the model of care, especially in Catalonia where a mixed provision coexists.
We would like to emphasise some positive achievements to be remarked as facilitators:
Otherwise, we have identified some barriers. They have been analysed and some actions are being incorporated in the PIAISS. We could describe the following barriers:
Implementing an integrated care strategy is a long journey and this will take time and patience. A shared vision is required and hard work must be carried out to align all the elements which help and encourage an integrated care scenario (Figure 7).
Our experience generates interesting lessons for other countries and regions who are working in a similar transformational project.
We would like to mention and share some of these lessons:
In addition, some lessons could be taken related to new trends and innovations in Europe:
Margrethe Smidth, PT, MSc, PhD, Postdoc, Department of Acute Care, Viborg Regional Hospital, Central Denmark Regional Hospitals, Viborg, Denmark
Denise van der Klauw, MSc., Research Scientist at The Netherlands Organisation for Applied Scientific Research TNO, Leiden, The Netherlands
One anonymous reviewer
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