The experience of Badalona municipality in integrating health and social care – Thoughts after 16 years of integrating health and social care region - contextualisation

• One of the 17 Autonomous Communities in Spain

• 7 million inhabitants

• Full competences in health services

• Catalan Healthcare Service (CATSALUT) acts as the purchaser of services

Catalonia region – contextualisationCat a(2)lan Healthcare System

Insurance Services 100% 20% The history of the Catalan healthcare CATALAN system, made it highly fragmented at a INSTITUTE OF HEALTH healthcare supply level: CATALAN 70% Around 80% of the specialized care HEALTHCARE

and around the 20% of the primary R

E SERVICE S CONTRACTED care is provided by suppliers not U belonging to the Department of PROVIDERS 20% Health

Supplementary 10% Inexistent common Information System Private Insurers Private Centres for all the healthcare suppliers due to the healthcare system diversification DEPARTMENT OF HEALTH: Draws up Health Plan and Transfers economic resources Plans Governance Source : Martinez (2013) and Contel (2014)

ICT’s Strategic component of the Healthcare System Catalonia region – contextualisation (3)

• Fragmented system: • 451 primary care centers • 831 local healthcare centers • 96 acute care hospitals • 96 intermediate care hospitals • 158 mental health centers • 42 centers for inpatient mental health care

• Social services entrusted to the Municipalities through the Department of Welfare and Family

Badalona Serveis Assistencials – who? Primary Care

7 primary care centers 117.823 assigned population 50% of Badalona city + 100% and Tiana

Structural resources 59 consulting rooms 36 nursery rooms 12 odontology rooms 6 social work rooms 11 continued assistance rooms 19 polyvalent rooms

CASSIR (sexual and reproductive health) 186.309 assigned population 50% of Badalona + 100% Montgat

Hospital Municipal de Badalona

Hospital Municipal de Badalona

237.244 assigned population All Badalona city

Structural resources

118 beds 8 short stay beds 16 rooms for outpatient services 27 consulting rooms 4 surgeries 30 emergency boxes

Centre Sociosanitari el Carme

Centre Sociosanitari El Carme

535.982 assigned population Cities of Badalona, Montgat, Tiana, Teià, Masnou and

Structural resources

209 beds 50 rooms for outpatient services 7 consulting rooms

Comprehensive care organization

• Network of care services that offers a coordinated service by means of a continuum of care

• Integration facilitates attention at the most cost effective location whilst also favouring aspects of promotion or prevention

• New organizational focus boosts innovation aspects on both a collective and an individual level

• Constant revision obliges the incorporation of the patients’ and citizens’ view Situation before year 2000

Health care silo: Social care silo: •Integral healthcare organisation •City Council in charge of the social services

•1,170 professionals •65 professionals

•70M € funding •4,7M € funding

•Providing classic healthcare •Providing: services – Telecare (panic button) – Meals at home – Cleaning at home

Why merging health and social care?

• Badalona City Council: • Unique holder of BSA • In charge of the provision of social services • Efficiency > Duplication of structures • Efficacy > Lack of coordination

Year 2000 • Shared decision between BSA and the City Council • Centre the model into the patient and merge delivery • Merge of both departments at a political level Situation after 2003 (numbers from 2015)

• Broke the wall separating both silos

• Creation of the Home Care Department to deliver the integrated services

• 1,200 professionals

• 67M € funding in total

• 3,5M € of those for subcontracting 3rd party providers in the social field How did we manage it?

Interesting Commitment to organization for customers employees

Strategic Lines 2003 - 2007

New targets according Enviroment to the health sector envolvement

Efficent use of comprehensive model organization Integrated care perspective - past

Patient perspective

Organisational Public health and perspective management perspective

Integrated care perspective Clinical Logistic perspective perspective

Economic Policy perspective perspective Integrated care perspective - current Case management

Case management is the procedure where the nurse coordinates the provision of care to guarantee the accomplishment of needs, through the control of symptoms and the management of the most adequate resources, to empower the autonomy of patients.

How did we organize it?

• Nurse leading the coordination

• Multidisciplinary teams doing continuous assessment and reassessment of needs

• Different pathways / programs have been put in place to tailor them according to the patients needs

• Put the patient in the middle of the care process • Engage the family and the community assets within the care process

• Continuous evaluation to improve the services provided

History of the Homecare service

HEALTH SERVICES Home hospitalization HEALTH SERVICES Frail geriatric patient setting Residence team Palliative care HEALTH SERVICES HEALTH New ATDOM Complex chronic patients (COPD) Complex chronic patients SERVICES model 1st ATDOM team (COPD+stroke+heart failure) Regional case Big roll-out Early discharge team 2nd ATDOM team management Regional Case SOCIAL SERVICES SOCIAL SERVICES EU projects: Management Help at home SIMAP (GPS tracking) ReAAL EU projects: Cleans at home Mastermind Birth of the Technical help Telecare Integral home help BeyondSilos Homecare Meals at home Home fixings Service EU projects: EU projects: HSH and Aladdin SOCIAL WORK Insup-C (collaboration) ACT (collaboration) Do Change (granted) REHABILITATION Usecare (granted)

2003 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2004 Catalog of services

• Social services: • Health services: • Help at home • Early discharge program • Telecare setting • Home hospitalization • Meals at home • Special tests • Cleaning at home • Geriatrics team • Home fixings (3rd sector) • Palliative care team • • Social isolation and social ATDOM program exclusion avoidance (3rd sector) • Residential team • GPS tracking system • Regional Case Management • Oncologic Regional Case Management • Telemonitoring Inclusion based on ICT

Stratification tool Other providers General inclusion criteria Enrolment in tailored pathway Social Services Health services

Emerg provision encies Specialized care

Integrated CM Social services Intermediate Care Primary care Record provision care Some outcomes of integration

Regional Case Management Program: • Characteristics of the patients: 76 years ratio, 52% woman, 1,38% prevalence, 20% with social problems • Interventions done: 86% VGI, 76% flu vaccine, 85% pneumococcus vaccine, 54% ATDOM program, 78% full assessment program • Results: 12% reduction GP, 8% reduction nurse (PC), 40% reduction emergencies, 56% reduction of non-programed hospital admissions, 23% increased QOL, 89% increased satisfaction with the service, 59% increased death at home

Early discharge Program: • Characteristics of the patients: Acute episode (normally hip fracture), living alone or with couple, risk of dependency • Interventions done: Family worker at home, home hospitalization (including specialist and nurse), rehabilitation team at home • Results: 67% increased complete rehabilitation (for patients between 70 and 83), 28% reduction relapse, ratio of 6,7 weeks to rehabilitation, 27% decreased mortality rate

Conclusions

• Initial driver of integrated care -> policy commitment towards a patient-centric model

• Reorganisational process and the governance - > main drivers of integrated care

• Health and social care professionals -> leading role in integrated care deployment

• Interoperable information systems -> fostered the full deployment

• Absence of major conflicts between the distribution of resources and the alignment of incentives

Conclusions (graphically) Highlights

• Achieving a full integration of health and social services is a slow process • It’s better to start with health services -> primary care gatekeeper • Problems for achieving it are organizational and cultural • Expect huge resistance from professionals • Integrated common care pathways should be developed • A continuous review process should be put in place to keep monitoring and improving the services / programs • Proper quality and cost-benefit evaluation needs to be conducted • The financing system should be ready

ICT support

• IT is a tool that will help you within the process, but not the solution • EMR, SCR, ICR and shared care plan are central • Innovation should be totally integrated in the organizations • Surround you by the quadruple helix of innovation and everything will be better

Thank you! Jordi Chief Information and R&D Officer Badalona Serveis Assistencials [email protected]