Patient management in COPD: the experience of the Nexesproject
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1 Symposium Dossier patient électronique: quel rôle pour le patient? Elektronisch patiëntendossier: welke rol voor de patiënt? Patient management in COPD: the experience of the Nexesproject Albert Alonso Innovation Directorate
2 Integratedcareat HCB
3 Evolution of COPD patients Source: Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. BMJ 2005; 330(7498):
4 Focus on exacerbations Source: Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. BMJ 2005; 330(7498):
5 Home hospitalisation programme COPD patients admitted at the emergency room Simple intervention Home hospitalisationwith free patient phone access to a specialised nurse Expected outcomes Better clinical outcome at lower direct costs than inpatients Lower rate of emergency room (ER) relapses Greater improvement of health-related quality of life (HRQL) Better patient self-management of the disease
6 Home hospitalisation programme COPD patients admitted at the emergency room Simple intervention Home hospitalisationwith free patient phone accessto a specialised nurse Expected outcomes Better clinical outcome at lower direct costs than inpatients Lower rate of emergency room (ER) relapses Greater improvement of health-related quality of life (HRQL) Better patient self-management of the disease
7 Home hospitalisationprogramme Exacerbated COPD patients (222) Home Hospitalisation (121) Control group (101) ER Intervention Discharge Discharge Home Intervention < 24h Accessibility Visit Outpatient clinic 8 wk after discharge
8 Home hospitalisationprogramme Exacerbated COPD patients (222) Home Hospitalisation (121) Control group (101) ER Intervention Discharge Discharge Home Intervention < 24h Accessibility Visit Outpatient clinic 8 wk after discharge
9 Home hospitalisationprogramme ER Intervention Focus on non-pharmacological treatment and education (duration 2 h), covering: Knowledge of the disease; adherence to treatment; and recognition/prevention of triggers of exacerbation Training on administration of pharmacological treatment Smoking cessation Empowerment on daily life activities: hygiene, dressing, household tasks; leisure activities; breathing exercises; and, skeletal muscle activity Nutrition recommendations Socialisation and changes in lifestyle
10 Home hospitalisation programme Readmission Emergency room visits SGRQ Total 28% Control group 20% Intervention group 22% 10% ** ** Savings **
11 Home hospitalisation programme
12 Home hospitalisation programme
13 Home hospitalisation programme
14 Focus on preventing exacerbations Source: Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. BMJ 2005; 330(7498):
15 Focus on preventing exacerbations Stable COPD patients after discharge Intervention Simple, well-defined integrated care intervention with the support of ICT Shared-care arrangements between primary care teams and hospital teams Expected outcomes Effective to prevent hospitalisations for exacerbations in COPD patients
16 Focus on preventing exacerbations Stable COPD patients after discharge Intervention Simple, well-defined integrated care intervention with the support of ICT Shared-carearrangements between primary care teams and hospital teams Expected outcomes Effective to prevent hospitalisations for exacerbations in COPD patients
17 Shared care / redefining roles
18 ICT support
19 Prevention of exacerbations programme
20 Integratedcareat HCB
21 Integratedcareat HCB
22 COPD evolution and Nexesservices Home Hospitalisation Enhanced care Rehabilitation Source: Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. BMJ 2005; 330(7498):
23 Programmes in Nexes Home Hospitalisation Complete substitution of an acute hospital stay in the patient s home. Hospital-based integrated care unit ICT: Call centre, Patients management application, mobile technology Enhanced care Prevent hospitalisations in frail patients (high rate of admissions) Transitional Care after discharge /Palliative care Frail patients in the community (low & high complexity) ICT: Call centre, Patients management application, Mobile technology Rehabilitation Empower patients active role (physical activity, self-management) Clinically stable COPD/CHF/coronary disease. Community based. Goal: reduce conventional interactions with the health system, improve life-style ICT : Mobile technology, Personal Health Folder
24 Conceptual service model in Nexes Normalisation Redefinition of roles Allocation of resources ICT Integrated care (80%) Traditional care (20%) Adapted from Berg M et al. Health Information Management. Integrating information technology in health care work. Routledge 2004.
25 Building blocks of Nexesprogrammes Work plan definition Case evaluation Case identification Follow-up & event handling Discharge
26 Detailed programme development Each programme is composed of a set of normalised actions as well as evaluation tools that target precise service objectives Integrated Care Team Specialised care Primary care Patient & Carer Social care
27 Detailed programme development Planner Pre-defined Template Personalized
28 Detailed programme development Patient & Carer
29 PatientHealth Folder
30 PatientHealth Folder
31 PatientHealth Folder
32 PatientHealth Folder
33 PatientHealth Folder
34 Wellness& Rehabprogramme
35 Take home messages Hospital Clínichas adopted Integrated care programme as a practical strategy to cover a variety of needs of COPD patients as the condition evolves, meeting expectations of patients, professionals and managers. This is so because they offer a flexible solution to coordinate care across providers, address co-morbidities and potentially allow the integration of social care services or other community based support ICT is a needed enabler for these programmes but not a necessary determinant of success.
36 Thank you for your attention Albert Alonso Nexes is a EU funded project (ICT PSP programme #225025)
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