The journey from a Chronic Care Program to an Integrated Health and Social Care model in Catalonia

1. © 2014 IBM Corporation 1© 2015 IBM Corporation
Mr. Juan Carlos Contel,
Department of Health,
Government of
Catalonia, Spain

2. The journey from a Chronic Care
Program to an Integrated Health
and Social Care model in Catalonia
Singapore, 28th
May 2015
“Integrated Care in Practice”

3. Session structure
• A new and different Health Plan and the
introduction of a new STORY
• Chronicity Prevention and Care
Program: the “journey” toward Integrated
Care
• Complex Chronic Care as catalyst of
Integrated Care
• A new journey toward a new Integrated
health and social care model
• ICT developments to support new
Integrated Care model: shared eHR (HC3)
and “i-SISS.cat” contribution
• Integrating health and social care information

4. The Spanish National Healthcare System
• NHS funded by taxes
• Decentralized to regional autonomies
• Universal coverage
• Free access
• Very wide range of publicly
covered services
• Co-payment in pharmaceutical products
• Services provided mainly in public facilities
• Interterritorial Board to coordinate policies

5. Catalan Healthcare System: some basic features
• Area: 32,106 km2
• Population: 7,611,711 inhabitants. 17% over 65 y.
(expected 32% in 2050)
• 1780 € expenditure per capita and 1150 € public expenditure
per capita in 2012
• Life expectancy: 82.27 years
• Gross Mortality rate (2010):8/1,000 inh.
• Infant mortality (2010): 2.6 /1,000 live births
• 369 Primary Health Centres (PHC) ranging from 20-45,000
inh)
• 69 “acute hospitals” (no far from 50 Km. from every home)
• 96 “long term care” centres (residential homes: long-stay,
convalescence, pal.liative care)
• 41 Mental Health Centres

6. Public System Network:
• 367 Primary Care Teams
• 69 Acute care hospitals (14,072 beds)
• 96 Long-term care centers
• 41 Mental healthcare centers
Healthcare data
Primary Health Care (PHC):
•Almost 1500-2000 inh. per family
doctor and community nurse
•Salaried + Bonus related Payment
by Results (betw. 8-12% salary)
•Availability specialty in family
Medicine (4y.) and Community Nursing
(2y.)
•Well implemented PHC evaluation
framework for all professionals

7. Catalan Healthcare System
U
S
E
R
U
S
E
R
SERVEI
CATALÀ
DE LA SALUT
100%
SERVEI
CATALÀ
DE LA SALUT
100%
SUPLEMENTARY
PRIVATE
INSURERS
20%
SUPLEMENTARY
PRIVATE
INSURERS
20%
INSTITUT
CATALÀ
SALUT
(public)
77%
INSTITUT
CATALÀ
SALUT
(public)
77%
PRIVATE
CENTERS
10%
PRIVATE
CENTERS
10%
CONTRACTED NON-
PROFIT PROVIDERS
23%
CONTRACTED NON-
PROFIT PROVIDERS
23%
Commissioner PHC Provision

8. Catalan Healthcare System
U
S
E
R
U
S
E
R
SERVEI
CATALÀ
DE LA SALUT
100%
SERVEI
CATALÀ
DE LA SALUT
100%
SUPLEMENTARY
PRIVATE
INSURERS
20%
SUPLEMENTARY
PRIVATE
INSURERS
20%
CONTRACTED
PRIVATE
NON-PROFIT
PROVIDERS
75%
CONTRACTED
PRIVATE
NON-PROFIT
PROVIDERS
75%
PRIVATE
CENTERS
10%
PRIVATE
CENTERS
10%
INSTITUT CATALA
SALUT (public)
25%
INSTITUT CATALA
SALUT (public)
25%
Commissioner Hospital Provision

9. Source: IDESCAT, 2015
Ageing in Catalonia 2013-2051
In 2050:
1/3 over 65 y.
>12% over 80y.

10. Total population: 7,49 million in 2013 and 7,95 million in2051
Elderly projection:
•> 65 y.: 1,30 million in 2013 and 2,45 million in 2051
•> 80 y.: 0,41 million in 2013 and 0,94 million in 2051
•Centenarians: 1.700 in 2013 and 21.600 in 2051
Life expectancy at 65 years:
Men: 18,7 in 2012 and 22,6 in 2050 (4-year increment)
Women: 22,7 in 2012 and 26,5 in 2050 (4-year increment)
Life expectancy at birth:
Men: 80 in 2015 and 85,33 in 2050 (5-year increment)
Women: 85,6 in 2015 and 90,21 in 2050 (5-year increment)
Population projection 2013-2051
Source: IDESCAT, 2015

11. Hospital admission by diagnostic groups > 70 y.
Source: DGPRS. Dep Salut, 2013
COPD
HF
Urinary Infection
Asthma
Diabetes with complications

12. Source: Catalan Health Plan 2011-2015.
The Catalan Health Plan 2011-2015
Health Programs:
Better health and
quality
of life for everyone
Health Programs:
Better health and
quality
of life for everyone
Transformation of the
care models: better
quality, accessibility
and safety in health
procedures
Transformation of the
care models: better
quality, accessibility
and safety in health
procedures
Modernisation of the
organisational models:
a more solid and
sustainable health
system
Modernisation of the
organisational models:
a more solid and
sustainable health
system
I
II
III
For each line of action, a series of strategic projects will be developed, which
make up the 31 strategic projects of the Health Plan.
For each line of action, a series of strategic projects will be developed, which
make up the 31 strategic projects of the Health Plan.
9. Improvements to information, transparency and evaluation
1. Objectives and health
programs
7. Incorporation of professional and clinical knowledge
6. New model for contracting health care
5. Greater focus on the patients and families
8. Improvement of the government and participation in the system
2. System
more
oriented
towards
chronic
patients
3. A more
responsive
system from
the first levels
More PHC !!!
4. System with
better quality
in high-level
specialties
Launched at the end 2011

13. Strategic lines of the Chronic Care Program
Allstrategiclinesrequire
ICTtoolsanddevelopments

14. • Integrated Care Pathways as a formal agreement among
professional clinical leaders at local level
• Based on reference clinical guidelines and
best evidence practice
• Critical key points identification
• Critical variables uploaded at Shared Clinical record
• 80% of territories implemented 3 of 4 chronic conditions:
COPD, depression, heart failure and DM2. Now Complex Cronic Care
Pathways work
• Agreement on different “situations”: 0. Diagnosis, 1. Stable,
2. Acute exacerbation, 3. Management difficulty, 4. Transitional
Care, 5. 24/7 guarantee (!)
Integrated Care Pathways

15. Healthy
33%
Chronic non complex
62%
Complex
3,5%
Advanced
1,5% End of life Bereavement
PREVENTIVE APPROACH
CURATIVE APPROACH
PALLIATIVE APPROACH
SELFCARE
COLLABORATIVE CARE
Taking care of complex patients

16. 16
PCCMultimorbidity
Severe unique disease
Advanced frailty
MACALimited live prognosis
Palliative approach,
Advance care planning
Two profiles of complexity
Stratification must be validated by clinicians determining
“complex chronic condition and advanced chronic disease”
condition

17. -Care centres that have patients classified and marked in these two
types, can publish this label/mark in HC3
- The classification / label must be visible on all the screens , given the
importance of the condition
- It has been incorporated in July 2013 version to HC3 stratification
with Clinical Risk Groups (CRGs)
PCC: Complex Chronic
Patient
MACA: Advanced chronic
disease

18. “Shared Individual Intervention Plan” (PIIC)
Health problems/Diagnosis
Active Medication
Allergies
Recommendations for “in case
of crisis” or exacerbation
Advanced Care Planning
Resources & SOCIAL services used
Multidimensional assessment
Carer whom are delegated decisions
Additional information of interest

19. Initial Health
Plan target (!):
25,000 complex
chronic patients
should be identified
by 2015
In May 2015 over
150,000 patients
included
1,5% of Catalan
population
Evolution in number of PCC and MACA
“Labeling” available since January 2013 !

20. NEW SHARED
INTERVENTION PLAN
(PIIC)
• Diagnostics
• Medication Plan
• Allergies
• Recommendations in case of
CRISIS or acute
exacerbations: dyspnea,
pain, fever, behavior change
• Advanced Care Planning:
preferences, values,
therapeutic adequacy
• Multidimensional
Assessment: functional,
cognitive and social risk
• Social Services utilization:
Home care, Home help,
telecare, case management
• Emergency admissions
and A&E visits in last 12
months
• Living alone ?
• Carer information

21. Basic assessment in Complex Chronic Patients
• Basic standardized and customized assessment: Functional +
Cognitive impairment + Social Risk + Depression
• NECPAL assessment to identify “Advanced Chronic Disease” condition
• Complementary assessment
Challenge:
To construct a
shared and joint
Health and Social
Assessment and
Intervention Plan

22. Multimorbidity unified data base
Insured data source
NIA, demographic data
Diagnosis data base
NIA, tipus_codi, codi, data dx ,UP,
tipus_UP
“Contact” data base
NIA, dates contacte ,UP, tipus_UP,
urgent, CatSalut, T_act.
MDS-Hospital
MDS-PHC
MDS-MH
MDS-Long Term
MDS-A&E
Central Registered
Insured
Health Problems
Pharmacy (PHC
and hospital
provided)
Pharmacy data base
NIA, ATC, data dispensació, unitats,
Import
Mortalitat (INE)
Data sources
MDS-Social Services MDS: Minimum Dataset

23. Multimorbidity in Catalonia obtained by stratification
Challenge:
It is required
to include
“social
data” to
adjust
stratification
http://146.219.25.61/msiq/index.html

24. DM2
COPD
DEPRE
OSTEOARTHRITIS
Prevalence of multimorbidity
Heart Failure
Information available at regional and PHC level

25. Stratification and Emergency admission risk
CRG RSC
Identification
people at risc
Proactive
measures
Classification people
at risk
Segmentation for
the proactive
management of
people at risk
Identification
and recording at
Clinical Record

26. Returning population stratified data base
Chronic disease selection
Hospitalization
s Risk
ID DM HF COPD Asthma Other: Nº
emerg
admis
ssion
Hospital
Cumulat
ive days
CRG
(status
and
severity)
Hospitaliz
ation
Rate
Mortality
Rate
ZAGO234… 1 1 0 0 1 3 18 7.4 80% 40%
ROGU675.. 1 0 1 0 1 1 8 7.3 65% 28%
 Selection of patients by different criteria
 Different pyramids related to different Risk approach:
Future hospitalization / Death / Future cost

27. 1% 18% 133% 10.992€ 13% 13%
2% 7% 57% 5.872€ 13% 26%
8% 3% 28% 3.162€ 28% 54%
17% 1% 14% 1.411€ 25% 79%
72% 0% 2% 282€ 21% 100%
POPULATION MORTALITY
RATE
HOSPITAL.
RATE
ESTIMATED
EXPENSE
% ACCUMU-
LATED
Impact distribution of different segments

28. Visualization in Shared Clinical
Record and different RISK scores
Morbidity group
and RISK calculated
and published twice
a year
Description
of different
RISK
segments

29. CRG information
(morbidity group),
severity and
Hospitalization Risk
CRG information
(morbidity group),
severity and
Hospitalization Risk
• CRG 7/5
• 3 emergency
admissions
• Hospitalization Risk
of 35%
PCC/MACAPCC/MACA
Included in “CASE
MANAGEMENT” Program
Included in “CASE
MANAGEMENT” Program
CRG and Risk score visualization

30. Ad-hoc “queries”:
Every professional could
perform a basic query
combining stratification and
current chronic conditions
and other variables
(pharmacy,…)
It could be selected 1 or
more chronic conditions
Stratification segment code

31. Expected per capita expenditure
Average expenditure (€)
Primary Care Pharmacy Emerg.adm. A&E Outpatient Clinics
AGE
Primary Care
Pharmacy
Emergency admissions
Outpatients clinics

32. Expected per capita expenditure
Average expenditure (€)
Primary Care Pharm. Emerg.adm. A&E Outpatient Clinics
COPDDiabet. Dement Card. CVAMent. Cirros. Kidney H. Fail. Neopl.VIH
Primary Care
Pharmacy
Emergency admissions
Outpatients clinics

33. Constructing a new GMA morbidity grouper in Catalonia
Source: CatSalut, 2014
Mortality PHC contacts Hospitalization A&E use
CRG vs GMA CRG vs GMA CRG vs GMA CRG vs GMA

34. Constructing a new stratification model for
Integrated health and social care
To identify people at higher risk to be
admitted in a nursing home or to be
home social care high intensity user

35. Proposal of sharing indicators
Indicators Primary
Care
Hospital
Care
Social
Care
Avoidable Hospital Admissions ++ ++ +
Home Care program Coverage ++ - ++
Health outcomes: good control,
process and treatment
++ ++
Readmission rate in Chronic
Obstructive Pulmonary Disease
(COPD) and Heart Failure (HF)
++ +++ +
COPD/HF Avoidable Hospital
Admission
++ ++
Discharge planning in “PRE-
Discharge” program
++ - -
To ensure continuity care in
“POST-Discharge” program
- ++ ++
“Quality of life” (HRQoL)
assessment
++ ++ ++Challenge:
To aggregate health and
social care data

36. New contract in 2013: Common PHC-Hospital Targets
38
COMMON TRANSVERSAL OBJECTIVES(20%)
Reduction Avoidable Hospital Admissions Rate (composite, HF and COPD)
Reduction 30-day Readmission Rate for HF and COPD (also composite)
Get minimum value prescription pharmaceutical index
% minimum discharges with contact before 48 hours after discharge
% minimum register screening risk factors Metabolic syndrome TMS
SPECIFIC TRANSVERSAL OBJECTIVES (“TERRITORY”) (20%)
% minimum PCC/MACA with Intervention Plan (“PIIC”)
% minimum PCC/MACA with medication review
% minimum PCC/MACA with post-discharge medication conciliation
Reduction emergency admissions in PCC/MACA
Minimum number participants Expert Patient Program
% minimum COPD patients with spirometry
% minimum PHC with Mental Health integration
Prevalence minimum depresion with “severity” criteria
% minimum patients with depresion with “suicide risk” assessment
Development at local level a consultant virtual office
“Amputation rate” reduction in DM
“Ophthalmology/locomotor “ referral first visits under expected tax
Challenge:
A new Shared and Joint
Integrated Health and Social
Care Outcome Framework
should be developed

37. SISAP: Professionals System Information
You MUST identify an
expected prevalence
Comparison with Team
and all organization
Screen display of indicators by doctors and nurses. (!) Monthly
data updated !!! Differentiated internal weight among indicators

38. SISAP: Professionals System Information
Comparison with Team, area, region and organization in Catalonia
Screen display of indicators by doctors and nurses. (!) Monthly
data updated !!! Differentiated internal weight among indicators

39. Heart Failure: patients treated with ACE
+2,4% last year variation

40. Multidimensional assessment in Home Care
+2,6% last year variation

41. Hospital admissions for chronic conditions
Monthly udpated information!
Includes: COPD, HF, DM complications, asthma, coronary diseases, HTA
Availability of evolution of avoidable emergency admissions for
a range of chronic conditions per region / sector / PHC team
(x 100.000 inhab. Tax)
Source: MSIQ, Catsalut
−8 %
last 36
months

42. Potentially avoidable hospital admissions for COPD
Decrease by 13,8 % from Dec 2011 to Dec 2013 (36 months)
Availability of evolution of avoidable emergency admissions per
region / sector / PHC team (x 100.000 inhab. Tax)
X 100.000 inh.

43. Potentially avoidable hospital admissions for
heart failure
Source: MSIQ, CatSalut
Decrease by 2 % from Dec 2011 to Dec 2014 (36 months)
Availability of evolution of Avoidable Emergency admissions per
Region / Sector / PHC Team (x 100.000 inhab. Tax)
New trend!
Increase by 26% from
2005 till 2011
X 100.000 inh.

44. Emergency admission rate in asthma
Decrease 5,8% between Dec. 2011 to Dec. 2014 (36 months)
x 100.000 hab.

45. Emergency admission rate related to diabetes
Decrease 14,2% between Dec. 2011 and Dec. 2014 (36 months)
x 100.000 hab.

46. 30-day readmission for a range of
chronic conditions (composite)
Decrease 8,5% between Dec. 2011 till Dec. 2014 (36 months)
Included: COPD, Heart Failure, DM, asthma, coronary diseases

47. Decrease readmission between Dec. 2011 till Dec. 2014 (36
months):
-6,5% COPD / -10% HF / -4,5% Asthma
30-day readmission for a range of
chronic conditions
COPD HF Asthma

48. Emergency admissions related to Chronic cond. exacerbation
Information
available at
“county” level
Almost the half
emergency
admissions
compared to
Catalan average
(x 100.000 inhab.)
“La Garrotxa” is an high
performing Integrated Heath
and SOCIAL Care county

49. Emergency admissions related to COPD exacerbation
More than the
half emergency
admissions
compared to
Catalan average
(x 100.000 inhab.)
“La Garrotxa” is an
high performing
Integrated Heath and
SOCIAL Care model

50. Emergency admissions related to HF exacerbation
Almost the half
emergency
admissions
compared to
Catalan average
(x 100.000 inhab.)
“La Garrotxa” is an
high performing
Integrated Heath and
SOCIAL Care model

51. Information available at
“county” level.
More than a half emergency
admissions compared to
Catalan average
(adjusted data)
Emergency admissions related to chronic conditions
La Garrotxa is an high performing
Integrated Heath and SOCIAL Care model

52. Emergency admissions in a “Primary Health Care team”
Almost 25% less
emergency
admissions for a
range of chronic
conditions
X 100.000 inhab.
Information
available for the 369
Primary Care Teams

53. List of patients sorted by “gaps”
ID PACIENT “GAP”

54. New “panel management”introduced
56
•It has been converted
information into warnings when
we access to clinical record in
each visit
•Customized configuration per
professional and Team
•Warnings sorted by importance
and relevance
•Weekly calculation (“online”
proposal)
•“Front-office” and “back office”
modality
Mean 20-30% improvement in some scores !

55. WARNINGS and ALERTS
Discharge Planning
Challenge:
To incorporate new
hospitals beyond
ICS and long term
care facilities
guaranteeing
“Transional care”
with Primary
Health Care and
Social Services

56. Basis for a Social and Health Integrated Care
Plan for Catalonia:
PIAISSPIAISS

57. Integrated Health
and Social Care
is high priority
and policy in
England
https://www.gov.uk/government/policies/making-sure-health-and-social-care-services-work-together

58. Direcció d’Atenció Primària Costa de Ponent

59. 25th
February 2014:
New Government Agreement
where is launched a new
Integrated Health and
Social Care Plan in Catalonia
Accountable and
reporting to
Department of
Presidency

60. Care model oriented to:
•To respond to people who have complex health and social
needs
•It is based on a shared participation in decision making by
the person
•To promote collaborative practice and co-responsibility
between the parties and a shared care plan elaborated by the
different professionals belonging to different organizations and
areas of care
•Triple Aim vision!: To achieve better health and wellbeing
outcomes, a more appropriate utilization of services and a
better perception of care
Integrated Care: PIAISS proposal

61. “Microsystems”
•Community-based and
primary care leadership
•Integrated care
pathways
•Multiprofessional work
•Transitional care
•Out of hours care
•Home care strategy
Joint case / care load:
Shared needs assessment
+ action plan
Stratification models:
assessing population needs
Clinical and
professional leadership
Health and social care
local governance
Shared outcome
framework: shared
responsibility & join
accountability Aligned incentives:
shared vision about
the use of resources
Shared Electronic Health
and Social record
Person Centered Care:
Empowerment and
Self-care
ENABLING ELEMENTS
Multi-lever approach:Multi-lever approach: ALL things at the same timeALL things at the same time
Culture and change
management
Catalonian Integrated Care model:
Set of elements to support Integrated Care

62. PIASS strategic lines:
Roadmap approved February 2014
Integrated, community-based care, i. e. primary social and health care
Integrated Care “Home care” model
Adaptation of long-term health and social care and mental health
Regulation of care in residential care facilities
Interaction between the health and social care areas of the mental
health and drug addiction and HIV/AIDS network
Improvement of the “dependency care” system
Integrated information systems
Collaborative and relational ecosystem
Sustainability and stability
Population-based framework of joint assessment
Integrated care as an innovative practice

63. Primary Care
Information from Centres/Hospitals
Specialist Care
Diagnostic
Procedures
Diagnostics
Prescriptions
Vaccination
Hospital Discharge Report
A&E Report
Specialist Care Report
Lab Results
RX Report
Other diagnostic reports
Hospital Data
Information from Dep of Health
Electronic
Prescription
Diagnoses
Procedures
Discharge Data
Prescription
Medication Plan
Shared Clinical Record (HC3) implemented

64. 67

65. Shared Medical Record – Summary display

66. Documents
published per year
29.270.546
2014 Images > 5 M
Image publication
Chronic patients labeled
24.837 MACA
More than
100 million
clinical
records
available
2014
113.354 PCC

67. Shared information systems: constructing a new eClinical
and Social care record
•CIP (Identification Number) as a common identifier.
•Prior agreement on the coding and register of social problems.
•Prepare the local social services information system for it to be
‘interoperable’ in a short-medium term and provide a minimum
set of information and variables for a Shared Social and Clinical
Record
•Access to a minimum set of information and variables of
common interest on social field for the Shared Clinical Record of
Catalonia (HC3).
1st stage: generation of a Social Intervention Plan incorporated to
HC3. 2nd stage: Shared Individual Intervention Plan.
•Communication systems to improve accessibility, messaging and
virtual work between social and health areas.
•Introduce social variables gradually to available health
stratification.
Challenges to construct and Integrated Health and
Social Care record

68. Health and socialHealth and social
integrated careintegrated care

69. Size of the project
72
PILOT
Health Department with HC3
(Shared Medical History of
Catalonia)
City Council of Barcelona with
SIAS (Social Services
Information System of
Barcelona).
Centres, programs and facilities of health and
social care, that are property of the City Council
of Barcelona and of the Health Department.
Phase 1 : Basic primary social services
Phase 2 . Specific social services
WHO IS INVOLVED?WHO IS INVOLVED?
PLANNINGPLANNING

70. Health and social information sharing
73
Category
HCCC (Shared Medical History of
Catalonia)
SIAS (Social Service Information System of
Barcelona)
ID
information
Name and surname
ID card
Date of birth
Address
Telephones
Age
Name and surname
Gender
Date of birth
ID card or passport
Address
Telephones
E-mail
Census
Services
information
Professionals
(general practitioner, nurse)
Health centre, palliative care, home care,
nursing homes...
Professional (social worker)
Social services centre
Supplementar
y information
Economic information: pharmaceutical copayment
Legal incapacity: process, date, guardian
Health
information
Health factors (diagnostic)
Chronically ill categorization
Very ill categorization
Disability: recognized level, kind of disability,
disable scale.
Dependent people: recognized level.
Risk alert (coronary heart disease, fall s...)
Needs
assessment
Barthel ADL index
Lawton-Brody's index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Barthel ADL index
Lawton-Brody's index
Pfeiffer cognitive evaluation test
Zarit Burden Interview
Social risk factors (Health at home - Salut a
Casa)
Social diagnosis
Intervention
Individual health intervention plan
Individual Treatment
Previous medical discharge (24-48 ours
before)
Medical discharge documents
A&E documents
EMS (emergency medical services )documents
Services:
 Home care services
 Telecare
 Food assistance
 Day care centres
Community
care
Programs/projects Programs/projects

71. “PCC / MACA”
condition
Shared Individual
Intervention Plan
(“PIIC”)
Diagnostics/
Health problems
“Dependency
degree” formal
assessment
“Home Help”
services label
“Telecare”
services label
Social Care
Intervention Plan
Pharmacy
prescription
Health CareHealth Care Social CareSocial Care
+ Social
“Health and Social” Integrated eCare
Pilot project in pioneer territories
Variables:
functional, cognitive
deterioration, ….
Variables:
functional, cognitive
deterioration, ….

72. Professional viewer HC3
Health professionals can use two methods look up information in
the HC3
Integrated into any health
information system

73. Legal framework
 REGULATIONS
 AGREEMENT
The “Framework agreement" has been signed between the Health Department and the
City Council of Barcelona concerning the exchange of information among HC3 (Shared
Medical History of Catalonia) and Social Service Information System of Barcelona.
 CONSENT
Informed consent to ask the citizen authorization to share their health and social
information.
 PERSONAL IDENTIFICATION NUMBER
The “Personal Identification Number” has been established as the common
identifier in health and social systems. 76
Law 12/2007, October 11th
, of Social Services and professionals who are involved in
the monitoring and evaluation of the citizen.
Law 21/2000, September 29th
, about the rights of information concerning the health
and autonomy of the patient, and clinical documentation.
Law 44/2003, Novembre 21th
, to regulate profiles of health professions.
Agreement GOV / 28/2014 of Febraury 25th
, to create the Integrated Health and Social Care
Plan (PIAISS), in the Government Plan 2013-2016, to promote, lead and participate in the
transformation of the social and health care model to achieve a person-centred integrated
care model.

74. SNOMED CT
• Example:
DescriptionIds
ConceptId
Hierarchy relationships
Social Problems codification

75. A Web Service is a method of communication between two electronic devices
over a network. This will be the way to share information between HCCC
(Shared Medical History of Catalonia) and SIAS (Social Service Information
System of Barcelona).
Security Common repository
 Informed consent will be signed by
the citizen.
 The health or social professional will
send the document to the common
repository .
 Each professional can check if the
citizen has signed this consent.
 Informed consent will be custodied in
a common repository.
 It will be validated by both systems.
 It will do periodic checks.
Send informationReceive information
Receive information
Send
informed
consent
and check
Technological terms
Send information
Health Departament
Information System
Social Service
Information System

76. i-SISS.Cat
Strategic plan for the implementation and
deployment of the platform for the
management of healthcare and social care
Processes in Catalonia

77. 80
• Management of the different clinical processes included and
priorised in the Healthcare Plan
• To introduce real virtual work substituting face-to-face work
• To assure interoperability between different providers, unifying
the model of integration and information sharing
• To share data and construct processes with Social Care provision
• To measure ”directly” the relevant indicators established within
the Health Plan and Catalan Outcome Framework
• To share with the patient and citizen the management of his/her
health in an enhanced self-management approach
The i-SISS.Cat solution should allow:

78. MAIN
CHALLENGES
1.GOVERNANCE
2.HOLISTIC POINT OF
VIEW.
3.INTEGRATED CARE.
GOVERNMENT 360º VISION
INTEGRATED
PROCESSES
INTEGRAL
VISION
•Creation of
programs and
tracking key
performance
indicators (KPIs).
•Display of results for
program and service
provider.
• Access to the broad
view of the patient
and the process
•Environments of
collaboration
between
professionals.
• Shared Social and
health-related
information
•MDT platform
• Platform that will
allow us to expand
the coverage to other
social benefits and
giving coverage to
the unique social and
health record.
The i-SISS.Cat solution challenges:

79. Integrated Care
Complex Care
Pathway with
Social Services
PHC
Sever.
Referral Appointment Results
PHC
Sec Care
PHC
To plan appointment
Treatment
response
Sec. Care
Good
Appointment
Bad
Results
HF
confirmation
Appointment
Outpatient
No HF
confirmation
Priority
PHC
Yes No
Stable
Yes No
Appointment
Outpatient
Admission

80. RISKRISK TO DEVELOP COMPLEX HEALTH AND SOCIALTO DEVELOP COMPLEX HEALTH AND SOCIAL NEEDSNEEDS
COMPLEX HEALTH
AND SOCIAL
NEEDS
HIGH HEALTHHIGH HEALTH
AND SOCIALAND SOCIAL
COMPLEXITYCOMPLEXITY
COMPLEXSOCIALNEEDS
COMPLEXSOCIALNEEDS
COMPLEXHEALTHNEEDS
COMPLEXHEALTHNEEDS
1
2
3
45
6 7
Complex health and
social needs ?
The need of
incorporating Social
Services in the
definition of a JOINT
Care Plan

81. Continuityof care
Integrated health and social care: shared approach
Multiple front door (mainly at
Prim. care). Unique response
Implementation
(efectiveness, coordination,
multidisciplinarity)
Join and comprehensive
assessment for health and
social needs
Shared proactive action Plan
Monitoring, evaluation and
feedback
person-
centred
Empowered citizens
- selfcare
Shared
information
Professional
leadership
Identification and registering
(in the community)
Community
based care
Casemanagement
/Sharedcare
Comprehensive
approach
Shared vision
& sharedoutcome

82. Shared needs assessment instrument
2 alternative options to be decided:
1.To adapt a validated commercial solution:
interRAI, SMAF,…
1.To construct a shared need assessment
instrument based on professional consensus
*It is required to facilitate collaborative environment
between professionals working in different areas of health
and social services

83. Multi-lever approach: ALL things at the same time
Catalan Integrated Care model: some lessons
• Strong Government commitment is required to overcome
current barriers, especially legal issues
• ICT interdepartamental governance is required:
Department Health and Welfare aligned
• Social care sector could understand and feel benefits to
use collaboratively health sector experience to accelerate
change and transformation
• Joint and intense working between Integrated Health
and Social care Plan and ICT departmental Unit
• Joint both health and social care commissioning teams
should be committed to joint commissioning
• To introduce incentives to encourage providers introduces
innovations and improvements
• Clinical and professional leaders should be involved in co-
producing “person-centered care” solutions