The Catalonian model for people

with complex care needs

Carles Blay
PPAC. PIAISS

4 major challenges in caring people in Catalonia the next decades

DEMOGRAPHY

SOCIAL COMPLEXITY

MORBIDITY

ECONOMY

The Catalan Health Plan 2011- 2015

Health Programs

1. Objectives and health programs

2. System
Transformation of
the care models

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

5. Greater focus on the patients and families

6. New model for contracting health care

Modernization of
the organizational
models

7. Incorporation of professional and clinical knowledge

8. Improvement of the government and participation in the system

9. Improvements to information, transparency and evaluation

Source: Catalan Health Plan 2011-2015.

2.1 Clinical pathways

2.2 Protection, promotion and
prevention
2.3 Co-responsibility and selfcare
2.4 Alternatives in an
integrated system

2.5 Complex chronic patients

2.6 Rational prescription and
use of drugs

What are complex needs?

According to a formal consensus by the official terminology agency of

Catalonia and clinical experts

Complex patients dont have an specific morbidity

profile.
Complexity is a perception of special difficulty by
referent professionals when trying to manage
patients needs and preferences.

Catalonian Health Plan: 2 profiles of complexity

PCC
Multimorbidity
Severe unique
disease
Advanced frailty

MACA
Limited live
prognosis
Palliative
approach,
Advance care
planning

Font: Programa de prevenci i atenci a la cronicitat. Departament de Salut. 2012.

THE VALUE OF CLINICAL JUDGEMENT:

Three steps to identify complex patients

1
Stratification
+
Clinical
characteristics

2
Subjective
criteria of
referent
professionals

Font: Programa de prevenci i atenci a la cronicitat. Departament de Salut. 2012.

3
The principle
of
improvement

A certain clinical profile

1
Stratification
+
Clinical
characteristics

Morbidity
Crisis
Evolution
Hospital or ER admissions
Polymedication & iatrogenic risk
Multidisciplicinarity
Uncertainty
Frailty or functional decline
Geriatric syndromes.

Font: Programa de prevenci i atenci a la cronicitat. Departament de Salut. 2012.

A perception of difficult management by

referent professional
MORBIDITY:
progression, severity, uncertainty

2
Subjective
criteria of
referent
professionals

PROFESSIONALS:
multiplicity, no-pathways

PERSONAL AND SOCIAL

CONDITIONS:
personality, functional status, material
needs, relationships and networks

SYSTEM:
fragmentation, provision

Font: Programa de prevenci i atenci a la cronicitat. Departament de Salut. 2012.

The principle of improvement

3
The principle
of
improvement

THE PROFESSIONAL

Font: Programa de prevenci i atenci a la cronicitat. Departament de Salut. 2012.

THE TEAM

THE TERRITORY

Evolution of complex patients identification from 2012 to 2015set

200000
180000
160000

MACA: 36.553

140000
120000

MACA

100000

PCC

PCC: 156.083

TOTAL

80000

TOTAL: 192.636

60000
40000

FONT: HC3, 2015

20000
0
2012

2013

2014

2015

Witch is a 2% of the total Catalonian population

And almost 50% of the target of complexity, identified in 3 years!

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The principle of improvement

THE PROFESSIONAL

NEW
PARADIGMAS IN
PROFESSIONAL
APPROACHES

THE TEAM

THE TERRITORY

REDESIGN OF
CARE PROVISION
TEAMS

CLINICAL
PATHWAYS FOR
COMPLEX NEEDS

Font: Programa de prevenci i atenci a la cronicitat. Departament de Salut. 2013.

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Key elements for improvement

Identification
Team/Unit Redesign
Integral assessment

ACP

Leadership
Expertise

Proactive planning

24/7

Transitional care
Co-ordination social resources

Case management
Intermediate care

Lessons learned after 200.000

Clinical judgement is valid and reliable
Prevalence of health complex needs is close to 5%
Advanced disease and palliative needs is around 1%
Multimorbidity is the most common attribute, but not unique

Stratification is useful, but not diagnostic

Mental health is somehow invisible
Palliative approaches are underestimated
Complex patients use more health resources
The application of the principle of improvement is effective

Adjusting data by age, gender and stratum

192.636
persons with
complex needs
have been
identified with a
integrative care
plan placed in
shared
information
platforms

Admissions x 2
Readmissions x 2
Length stay x 1.5
Mortality intrahosp x 3
Drug use x 2
Primary care x 1.5
Intermediate care x 3

192.636
persons with
complex needs
have been
identified with a
integrative care
plan placed in
shared
information
platforms

Only 57% of
complexity is
explained by
morbidity

Multimorbidity
and complexity
are strongly
related to social
needs

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Health and social integration:

a central topic for the future in Catalonia

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www.gencat.cat/salut/pladesalut

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