Verso le Cure Integrate ed oltre: Il progetto Beyond Silos

Transcription

1 Verso le Cure Integrate ed oltre: Il progetto Beyond Silos Guido Iaccarino, MD, PhD, FESC Associate Professor of Internal Medicine Univerity of Salerno AOU San Giovanni di Dio e Ruggi d Aragona Osservatorio per le Deospedalizzazioni 1

2 Ageing society Lack of health professionals Chronic conditions Financial challenges HLY vs LE Health inequalities

3 Campania- An ageing region» Very densely populated, an increasingly ageing population» 6 universities, 3 medical schools

4 Risk Stratification

5 Proiezione del numero di posti letto occupati in Scozia ( )

6 Indici di funzionamento della AOU San Giovanni di Dio e Ruggi d Aragona Posti Letto Dimessi in Ricovero Ordinario Giorni di degenza Degenza Perc_casi media _C_RO Percentuale di Tempi di Occupazione AOU San Giovanni e Ruggi ,18 33,05 72,26 Ruggi - Salerno ,46 39,01 78,17 G.Fucito - Mercato S.Severino ,83 22,84 60,47 Giovanni da Procida - Salerno ,49 1,37 77,94 S.Maria Incoronata dell'olmo - Cava de Tirreni ,35 30,01 58,54 AOU San Giovanni e Ruggi ,03 32,11 81,9700 Delta % % 12% 2% -21% -3% 13% Ipotesi delta ,33 31,19 92,98 Ipotesi delta ,

7 Progettazione europea per la deospedalizzazione: Smartcare

8 Taking integrated care a step further... BeyondSilos will further spread ICTenabled, joint-up health and social care for older people by developing, piloting and evaluating integrated services based on common pathways in a multi-centric approach, making extensive use of knowledge and experience gained among early adopters of integrated ecare in Europe.

9 Background» National welfare & health systems and regional/local support practices were developing more and more specialisation and clear boundaries closed them to cooperation Today» Today s reality is characterised by fragmentation and bureaucracy in current provision systems resulting in disjointed and patchy support services» Leading to inefficiencies, duplication of resources, and potentially to reduced levels of quality of care Tomorrow Social care Healthcare Informal care

10 Objectives» Implement and pilot integrated social and health care services in seven sites across Europe» Utilise ICT tools (from home health monitoring to shared data records) to enable better cooperation between care professionals, family members and those receiving care» Base services on care pathways cutting across boundaries which typically separate health care from social care» Generate multidimensional evidence on impacts of integrated care on all stakeholders concerned through common evaluation approach transferable to follower-regions across Europe

11 BeyondSilos in a nutshell» March February 2017» Total budget 5.47 m» Co-funded by the European Commission within the ICT Policy Support Programme of the Competitiveness and Innovation Framework Programme (CIP)» Pilot B» 13 partners, including service providers, IT providers, researchers and consultants» Integrated services will be implemented and piloted in the regions of Northern Ireland Sofia in Bulgaria Badalona and Valencia in Spain Campania in Italy Amadora in Portugal Kinzigtal in Germany» Co-ordinated by the Health and Social Care Board (HSCB), Northern Ireland with support from HIM SA, Belgium

12 Objectives BeyondSilos integrated care programmes collaborative inclusive safety enhancing responsive Self-care efficient empowering Health care Cared for person Social care Informal/family carer Integrated data access BeyondSilos integrated pathways Coordination Real-time communication Joint response Access to home-based systems: Telemonitoring/Telecare BeyondSilos ICT integration infrastructure building blocks Operational deployment of novel integrated care programmes Pilot & validation in 7 European regions Multidimensional evidence on impacts Homogeneous care pathways and homogeneous methodological approach Transferable to follower-regions across Europe Learning from early adopters Plans for sustainable mainstream operation Large scale dissemination Major contribution to EIP AHA & other EU/nat./regional initiatives

13 Campania- The starting point» Regional government provides integrated care at home (ADI) to to patients with high needs for social and healthcare support» A process of evaluation is therefore needed to identify the patient/client» Process is started by the GP, but also from Hospitals and Health District Specialists

14 » The system is based on papers and there is no ICT involved. Only recently the Salerno ASL has implemented an ICT platform that handles the request of service, but no health record is involved so far

15 Campania- The BeyondSilos service» The AOU San Giovanni di Dio e Ruggi d Aragona uses ICT for the management of chronic patients: WINCARE/WEBCARE» This ICT is shared with the GPs of the Salerno territory and accessible from the internet» A similar solution is also present in Naples» The ICT provides an EHR and is used as the EHR platform in BeyondSilos

16 Campania- The BeyondSilos service» With the project WINCARE/WEBCARE are implemented with telemonitoring modules

17 Innovative tasks of BS in Campania Pilot Site» Identification of patients is a task that was arranged together with the ADI (Assistenza Domiciliare Integrata, Integrated Home Care) of Salerno and Napoli. In particular, it was agreed that patients with some level of heart disease according to the American Heart Association/American College of Cardiology definition of the severity of the disease (4 classes, from A to D) are to be chosen.» It is agreed that the patients could have other co-morbidities, in order to be enrolled.» home monitoring of biometric parameters in patients. This task has been subcontracted to Magaldi life which is also requested to instruct the patients and relatives on how to use the devices.

18 Screen Shot Beyond Silos

19 Screen Shot Beyond Silos

20 Screen Shot Beyond Silos

21 Workplan Requirements Elicitation & Pathway Development ICT-supported integrated care programme preparation Pilot preparation, operation & evaluation WP1 Requirements & integrated pathway development WP3 Integration Infrastructure Architecture and Service Specification WP5 Pilot site preparation and operation WP2 Organisational models and service process models WP4 System implementation & test WP6 Pilot evaluation WP7 Exploitation support & dissemination WP8 Consortium management & performance monitoring

22 The pilot sites» Amadora, Portugal» Badalona, Spain» Campania, Italy» Kinzigtal, Germany» Northern Ireland» Sofia, Bulgaria» Valencia, Spain» Follow a common programme for service development and implementation that specifically takes into account the requirements of users and care professionals, of service providers and business experts

23 Life Expectancy Costs (fonte: OCSE)

24 Health Status Perceived (fonte: OCSE) Percezione dello stato di salute