In a context of growing incidence of chronic diseases and ageing populations, there is the need to research and find new solutions to shift resources into the community in an effort to deal more effectively with chronic conditions. In that direction, patient empowerment plays an important role. Approaches to increase patient empowerment vary from patient self-management programs, to promoting patient involvement in treatment shared decision-making, to facilitating the clinician-patient cooperation. This talk focuses on self-management as a way to engage and empower patients in order to improve their quality a life and to allow a better follow-up by clinicians. A practical example from the CONNECARE project will show how self-management could be put in practice for supporting complex chronic patients.

1. Patient Empowerment from
an Integrated Care Perspective
Eloisa Vargiu
eloisa.vargiu@eurecat.org
Source: https://biopsy.wordpress.com/2009/04/06/patient-empowerment/
1st Edition COMP-MED: Computational Methods in Translational Medicine

2. 1st Edition COMP-MED: Computational Methods in Translational Medicine 2
Source: https://www.floptv.tv/flog/la-nuda-verita/pensionato-fugge-dalla-casa-di-riposo-per-fissare-un-cantiere/
The Context

3. 31st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Ageing Population
An ageing population and the increasing number of
people with at least one chronic disease are
demanding more resources and increasing the
burden on health and social care systems

4. 41st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Chronic Patients
Source: https://health.usnews.com/health-news/health-insurance/articles/2015-12-23/how-to-get-the-best-plan-when-you-have-a-chronic-illness
Chronic diseases are the leading
cause of mortality and morbidity in
Europe, the major cause of
disability, the principle reason why
patients visit physicians, and the
reason for 70% of health care
expenditures

5. 51st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Complex Chronic Patients
 It is a clinical assistive concept
 There is not a unified definition
 Complex Chronic Patient (CCP): A person with
a health and social care perceived quite
difficult by the team of professionals in charge
 Complex Chronic Patient (CCP): A patient with
one or more chronic condition, with
comorbidities or multimorbidities for causes
 Intrinsic: clinic o dependent on the treatment
adherence
 Extrinsic: social and/or dwelling environment
has several problems with high frequency and
needs several resources

6. 61st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Complex Chronic Patients
 5% of the population
 40% of the health budget is devoted to give
support to this kind of patients
 40% of the patients are in acute
hospitalization

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Photo Credit: photoloni | Flickr
Effects and Underlying Problems

8. 81st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Increasing of Health Costs
 Movements from home to hospital/medical facilities
 Number of (re)-hospitalizations
 High resources in terms of professionals involved
Quality of Life Worsening
 Patients, familiars, and caregivers frustration
 Anxiety, depression, and mental disorders
 Loss of confidence in the health system
 Waste of time

9. 91st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Lack of Coordination

10. 111st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Lack of Coordination in Practice
Source: https://www.connecare.eu/

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The Goal

12. 131st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
The Goal
understanding by the
patient of her/his role
acquisition by patients of sufficient
knowledge to be able to engage with
their healthcare provider(s)
patient skills
the presence of a
facilitating
environment
Empowerment

13. 141st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Patient Empowerment
A process through
which people gain
greater control over
decisions and actions
affecting their health

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The Way

15. 161st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Integrated Care
 Integrated care models are
designed to respond to the
effects and problems listed
before
 The defragmentation of
health and social care
systems
 The promotion of
collaboration and continuity
among care settings
 A move from institutional,
reactive care to a home-
based, patient-centred,
preventive model
INTEGRATED
CARE
Enhancing
the value of
care
Cost
efficiency
Efficiency
and
outcomes
improveme
nt
User
Experience

16. 171st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What is Integrated Care?
References/sources:
Lewis R, Rosen R, Goodwin N, Dixon J. Where next for integrated care organizations in the English NHS? London: The King’s Fund; 2010.
Fulop N, Mowlem A and Edwards N (2005) Building Integrated Care: Lessons from the UK and elsewhere. London: The NHS Confederation.

17. 181st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
The Chronic Care Model
Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

18. 191st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Evidence on Effectiveness of the
Chronic Care Model
References/sources:
Zwar, N., Harris, M., Griffiths, R. et al. (2006) A Systematic Review of Chronic Disease Management. Sydney: Australian Primary Health Care Institute.
Wagner EH. Care of older people with chronic illness. Older People Build Syst Ased Evid. 1999;39–64

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The Tools

20. 211st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Patient-centred Care
A way of thinking and doing
things that sees the people
using health and social
services as equal partners in
planning, developing and
monitoring care to make sure
it meets their needs

21. 221st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Co-Design
Requirements
gathering
Patient-
centered
evaluation
Final
deployment

22. 231st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Stimulate Active Participation
Facilitating new forms of active
participation by patients and
consumers in the collection of
personal health data will improve
the quality of care delivered to
patients through better diagnoses
and targeted therapies
Source: https://velvetchainsaw.com/2010/04/14/stomaching-long-conference-lectures-is-out-active-attendee-participation-is-in/

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Patient Empowerment

24. 251st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Strategies
patient self-
management
programs
promoting
patient
involvement
in treatment
decision-
making
facilitating the
physician-
patient
interaction

25. 261st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Evidence on Effectiveness of the
Chronic Care Model
References/sources:
Zwar, N., Harris, M., Griffiths, R. et al. (2006) A Systematic Review of Chronic Disease Management. Sydney: Australian Primary Health Care Institute.
Wagner EH. Care of older people with chronic illness. Older People Build Syst Ased Evid. 1999;39–64

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Source: https://www.alliance-scotland.org.uk/blog/news/self-management-fund-review-2017/

27. 281st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Self-Management
Source: http://www.phsa.ca/Documents/patientselfmanagementpatrickmcgowanbc.pdf
The systematic
provision of education
and supportive
interventions by
health care staff to
increase patients’ skills
and confidence in
managing their health
problems, including
regular assessment of
progress and
problems, goal setting,
and problem-solving
support.

28. 291st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
maintaining
exercises and
activity levels
monitoring physical
indicators by objective
means
recognizing and responding to
symptoms and controlling
triggers to symptoms
drug prescription
and follow-up
maintaining nutrition and
dietary recommendations
giving up smoking
and drinking
using strategies to
relax and reduce stress
managing emotions and
psychological response to illness
adapting to
work/education
interacting with healthcare
professionals
seeking information and
using community resources
managing relations with
similar patients
managing alerts and
emergencies
Ref: Clark, N.M., Becker, M.H., Janz, N.K., Lorig, K., Rakowski,
W., Anderson, L.: Self-management of chronic disease by older
adults: a review and questions for research. Journal of Aging
and Health 3(1), 3-27 (1991)

29. 301st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
maintaining
exercises and
activity levels

30. 311st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
monitoring physical
indicators by objective
means

31. 321st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
recognizing and responding to
symptoms and controlling
triggers to symptoms

32. 331st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
drug prescription
and follow-up

33. 341st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
maintaining nutrition and
dietary recommendations

34. 351st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
giving up smoking
and drinking

35. 361st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
using strategies to
relax and reduce stress

36. 371st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
managing emotions and
psychological response to illness

37. 381st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
adapting to
work/education

38. 391st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
interacting with healthcare
professionals

39. 401st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
managing alerts and
emergencies

40. 411st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
seeking information and
using community resources

41. 421st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
What a Patient Should Manage?
managing relations with
similar patients

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How to Manage
Everything?

43. 441st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Underlying Needs
 Risk stratification
 Clinic validation
o Comorbidity
o Cognitive and emotional
o Functional
 Barrier identification
o Therapeutic adherence
o Self-care ability
o Physic environment
o Social environment
 A work plan agreed among primary care doctors and
hospital staff (need of communication)
 Preventive actions at ambulatory level

44. 451st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Use an Integrated Care Approach
 Improvement of communication and information flow between
primary care and hospital to work together
 Remote monitoring of clinic variables and improvement of
communication among the professional team and the patient to
prevent acute situations
“All together to anticipate problems”

45. 461st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Closed Loop Approach
 Primary care doctors and
hospital staff agree a work plan
 The plan includes the list of
tasks that the patient has to
perform
 Tasks consist on managing one
or more of the listed variables
 The patient self-manage her/his
status
 Professionals continuously
monitoring patient’s status
 Professionals may change the
work plan accordingly
 …

46. 471st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
An Integrated Care Solution

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Open Issues

48. 501st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
How to Engage the Users?
https://vimeo.com/128873380

49. 511st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Engagement vs Addiction

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51. 531st Edition COMP-MED: Computational Methods in Translational Medicine
Patient Empowerment from an Integrated Care Perspective – E. Vargiu (eloisa.vargiu@eurecat.org)
Wrap-Up
 Complex chronic patients require the 40% of
the health budget
 Right now coordination and communication
among hospital staff, specialists, and primary
care doctors is very fragmented
 Patients has to be empowered to better
manage their health status
 Professionals at any level have to coordinate
each other
 A continuous and remote follow-up is needed
 Quality of life must be improved!

52. GRÀCIES!
¡GRACIAS!
GRAZIE!
THANKS!
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eloisa.vargiu@eurecat.org