Evaluating the Impact of an Integrated Care Program

Abstract

An introduction: The Strategy of Care for People with Chronic Diseases (SCPCD) is one of the main strategies in the Madrid Region. This strategy proposes some key elements for its application in each territory in order to achieve a better integrated-care, elements that include interventions that have proven to be effective and efficient as well as the adaptation of the care model to the needs of the patients. The Westernarea of Madrid, in particular, the area of influence of “Rey Juan Carlos” Hospital, is a territory where continuity of care and the integration of services has become a priority. It is the Madrid areawith the highest percentage of patients with high level of risk. The institutionalized population in nursing homes constitutes 2.5% of the total population and it is estimated that 4% of the population has complex chronic diseases. It is considered as one of the most advanced area in the application of new care routes and tools and also with initiatives such as a social and health plan for the integration between the hospital and social services and nursing homes. Short description of practice change implemented: Between 2012 and the present time, and with the impulse of the SCPCD as reference, different projects including effective and efficient integrated interventions have been implemented in this region. These interventions have been described in a previous work and they are: new coordination structures, new rolls, new pathways for people with complex needs and in nursing homes, new ways of communications between professionals of different organizations, and new IT tools, with a shared electronic Health Record. and theory of change: The aim of the project is to evaluate the impact of an integrated care model in a territory within Madrid region, Spain. We will use as reference for obtaining indicators the Report on Results in of the Madrid Region and the Proposal of indicators to evaluate the attention to chronicity in the framework of the Strategy for Addressing Chronicity in the National Health Systemof the Catalan Agency for the evaluation of health technologies. Finally, we will use the Conceptual Framework of the Triple Aim as a reference scheme for the construction of our map of indicators Targeted population and stakeholders: We will take as reference the total population assigned to the “Rey Juan Carlos” Hospital at the cut-off date of December 31st, 2016: 174.000 inhabitants distributed in 18 municipalitiesfrom the West area of the Madrid Region. The institutionalized population in nursing homes belonging to this area will be also included as well as the population with a high level of risk using the Adjusted Morbidity Groups (GMA) grouper as a stratification tool. The managers of the different health and social institutions are also collaborating in the project as stakeholders. Timeline: The activities to developed will be: (1) Selection of Indicators; (2) Prioritization; (3) Build of Map of indicators (3) Obtention of data (4) Analysis comparing and following data from 2012 to 2016 specially for high risk-high needs and institutionalized people From January till April 2017. Highlights: The project will contribute to increase the knowledge in T4 Research as defined in the NIH Roadmap. This project has been approved as part of a set of studies promoted by a research team from the University of Berkeley and funded by the Robert Wood Johnson Foundation. Comments on sustainability: It is necesary to assess the impact of integrated program of iniciatives in real conditions to show its effectiveness and efficiency. Comments on transferability: We will establish a map of indicators of integrated-care that will allow the assessment of the impact of an integrated-care program in any territory. Conclusions: The final report with full results and conclusions will be finalized in April 2017. Discussions: Evaluating the impact of a program that includes different interventions, implemented with a variable time sequence, and in a population that is in turn influenced or contaminated by general health policies, or by non-controllable context factors, is difficult and represents a challenge. Lessons learned: The final report will summarize the results of the research oriented towards the detection of strengths and the development of improvements. The map of indicators will be an instrument to be use to assess and monitor the outcomes