Personal Health Systems and COPD how to integrate into routine health delivery?

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1 Personal Health Systems and COPD how to integrate into routine health delivery? From HealthCare to Health Promotion Josep Roca Hospital Clinic.IDIBAPS.University of Barcelona

2 HIGHLIGHTS CHALLENGE OF CHRONIC DISEASES A NEW RESEARCH PARADIGM TOWARD PERSONALIZED HEALTH

3 Catalonian healthcare system Agenda

4 Catalonia 7.5 million habitants Barcelona

5 The adaptation of the Catalonian Healthcare System to the new scenario generated by Chronic Disorders is a political mandate Health plan Burden of Chronic Disorders Elderly populations Co-morbid conditions Cost containment Coordination with community services

6 Agenda Setting the change ( ) Catalonian healthcare system

7 Shared care across the system Hospital Emergency team Consultant Case Manager Primary Care Home Patient Relatives & care givers Mobile teams Primary Care Team

8 Services Target patients Management by programs Well standardized interventions Patient-centered care Patient Triage Self-management Remote monitoring Support center providers network

9 A frame for a Program - Patients get access to an authorized center - Patients are assessed for entry into a program - Patients are monitored and followed up through mobile technology and internet. Interoperability Integrated Health Networks Bio-connectivity Professionals Patients

10 Information technologies supporting - enhanced citizens life style - well standardized care paths resulting in integrated care strategies for chronic patients Modulation of disease progress Efficient patient management

11 INTERVENTIONS Pilots and Services HOME HOSPITALIZATION PREVENTION OF HOSPITALIZATIONS HOME MONITORING HOME REHABILITATION HIGH QUALITY SPIROMETRY IN PRIMARY CARE TELE-DERMATOLOGY SLEEP STUDIES

12 Summary of Clinical Trials Clinical efficacy Behavioural changes Satisfaction Cost containment Improved prognosis?

13 Activity organized by care programs including clusters of diseases Cardiovascular Respiratory Diabetes - Obesity Fragile patients

14 Technological challenge Organizational challenge

15 Agenda Setting the change ( ) Deployment plan Catalonian healthcare system

16 Intramural program (consolidated within 2007) Transversal Unit Chronic Care Medical Direction Open I.T. Platform Linkcare spin off Supporting chronic care: modular & interoperable Biomedical research program IDIBAPS BioCat Educational program (professionals and patients) Forum Clinic

17

18 FOCUS Prevention Chronic diseases Dependency children adults elders

19 INTEROPERABILITY AMONG PROVIDERS Level A - Barcelona Esquerra Level B - Spain and Europe Patient summary record and electronic prescription BARCELONA ESQUERRA habitantes EAPs ICS EAPsCAPSE EAP Gesclínic EAP Les Hortes EAPsVallplasa Hospital Clínic Hospital SagratCor Clínica Plató CAP II Manso (ICS) CAP II Numància(ICS) 3C 5D 5E 4C 5C 4B 5A 5B 4A 3E 3G 2E 2C 3D 2B 2D 2A 3B 3A 18 ABS y 2 CAPs II (5 empresas distintas) 4 Hospitales 1 Centro Sociosanitario principal y otros de menor dimensión 3 Proveedores de Salud Mental Servicio de Emergencias Médicas de Cataluña

20 The Vision Deployment at Barcelona Esquerra

21 Deployment at Barcelona Esquerra 2009: Hospitals vs territorial healthcare HOSPITAL Community Care Process Units Transplant Dementia COPD CHF Territorial Healthcare Family Physician Nurse Social Worker Home Care

22 Institutions representative Deployment at Barcelona Esquerra 2009: Territorial Health Care Comission Barcelona Esquerra Permanent Comission Redesign Implementation & follow-up Technical Management Team Process 1 Process 2 Process 3 Process 4 Emergencies Specialized Care Social Care Health Transport Home Care Pharmacy Mental health Pediatric care IT Operational Committees

23 NEXES (Telemedicine program EU) RENEWING HEALTH (Telemedicine program EU) PITES (FIS, Carlos III)

24 Current Deployment at Barcelona Esquerra Main services deployed Wellness & Rehabilitation Frailty Transitional care Palliative care Home hospitalisation Support

25 Need for stratification by patient s risk profile Use of resources Disease phenotypes

26 New drivers A new paradigm in Biomedical Research: from bedside to bench and back to bedside

27 Agenda Setting the change ( ) Deployment plan Catalonian healthcare system Toward personalized care Summary

28 Roadmap System Medicine Programme Public Health Process redesign 1996 Research and pilots Deployment at Clinic 2007: Integrated Care Unit Linkcare platform Deployment at Barcelona Esquerra 2009: Sistema Informació Sanitari (SISBE) Problem-oriented information system Towards extensive deployment and adoption (from 2009) Ambient Assisted Living

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