Chronic Care Program Research Articles

Comparing complex chronic patients to advanced chronic patients with palliative care needs: cross-sectional study

Introduction : In Catalonia, a strategy for proactive identification of complex chronic patients (CCP) by healthcare professionals in primary care, based on clinical judgment and broad criteria (encompassing clinical and psychosocial variables), has been promoted by the Chronicity Prevention and Care Program (CPCP) from the Department of Health. Identification of CCP is recorded in the Shared Clinical Record of Catalonia, a common technological platform accessible to all providers of public health network. A differentiated identification and coding of those CCP that suffer from advanced chronic disease and present palliative care needs, coded as CCP-ACD, is recommended. Even though population-based studies determining prevalence and characteristics of CCP-ACD in Catalonia have been performed, comparative studies between this population and those that have been identified as CCP are not available yet. The aim of this study is to compare the characteristics of CCP identified by healthcare professionals in primary care according to clinical judgment and broad criteria with the characteristics of those identified as CCP-ACD. Methods : Information about demographic variables, presence of chronic diseases, use of health services and expenditure on pharmaceutical prescriptions was collected from the population morbidity database of Catalonia in 2013 (7.753.482 inhabitants). Identification of CCP and CCP-ACD was retrieved from the Shared Clinical Record of Catalonia on 31st December 2013. Statistical tests used for comparisons were Pearson's chi-squared test for qualitative variables, parametric test for mean comparison (Student's t test) and non-parametric test for median comparison (U MannWhitney). Results : Total CCP identified by healthcare professionals in primary care between 1st February and 31st December 2013 are 101415 persons (1.3% of the population of Catalonia), which are distributed in 83% PCC itself (84150 persons, 1.1% of the population of Catalonia ) and 17% CCP-ACD (17265 persons, 0.2% of the population of Catalonia ). Ratio CCP/CCP-ACD is 5/1. Descriptive characteristics of individuals identified as CCP itself respect those identified as CCP-ACD present a higher percentage of women (55.5% vs 53% , p 1000 €/year (43.5% vs 38%, p Descriptive characteristics of individuals identified as CCP-ACD respect those identified as CCP itself present a higher percentage of mortality (19.9% vs 4.1%, p 84 years (46.5% vs 35%, p €3000/year (7% vs 3%, p Discussion : Characteristics of individuals identified as CPP-ACD describe a profile, in terms of burden of disease and pattern of use of resources, typically of the end of life phase, clearly different from characteristics of individuals identified as CCP itself, suggesting that clinical judgment, promoted by CPCP as criteria for proactive identification of this population, would allow to differentiate these two groups. Prevalence of individuals identified as CCP-ACD is lower than, according to the literature, would be expected to find at a population level (around 1%), and probably related to limited study period, of only 11 months. Yet, ratio CCP/CCP-ACD found is higher than expected (about 3/1). These results might point out that CPP-ACP population would be under-registered, probably favoured by prognostic uncertainty and difficulties in identifying the typical needs profile of advanced diseases by healthcare professionals. Conclusion : Characteristics, in terms of burden of disease and pattern of use of resources, of individuals identified as CCP-ACD by healthcare professionals in primary care are clearly different from those identified as PCC, which would justify the implementation of health policies and models of care specific to each level of complexity. Additional studies are needed to overcome limitations of the present study, to establish the population prevalence of both CCP and CCP-ACD and to identify the possible causes of under-registration of CCP-ACD by healthcare professionals in primary care.

Risk Stratification as a tool to the Integrated Care in Mental Health in Catalunya

Introduction : In the last decade , the focus of the health care have slowly shifted from the acute care to the care of the chronic conditions . Several documents from the WHO indicated the path to a new paradigm of care . Significantly in 2008 the WHO Europe , has published “ How can chronic disease management programmes operate a cross care settings and providers? “In this document the mental Health problems , addiction condicions intellectual disabilities , brain injuries and mental health problems beguining at childhood ages have been taken in account. For decades , the mental health sector have been dealing with mental chronic conditions and developed programs and resources to manage the evolution of the mentioned conditions. The concept of Severe Mental illness has , actually , been loosing the significance to identify the complexity of the people who is attended in the Mental Health System , because the increase of comorbidities : physical chronic conditions , use and abuse of substances , mental health problems beguinning at childhood , intellectual disabilities , behaviour diseases ,.. , so a wide concept of SMD is need to be developed . Objective : To aligne the Mental Health chronic conditions inside the same stratification method for the physical chronic conditions ; we set a criteria to define the Chronic Mental Health Patient ( CMHP ) , a wide criteria for SMD , and Complex Chronic Mental Health Patient ( CCMHP ) : also we develop a 3 Clinical Risk Groups ( groupers ) for the Mental Health conditions , named GMA ( Adjusted Morbidity Groups ) , and we test the consistency and the prediction of needs of the identified people into these criteria. Taking in account social needs and involving the Primary care , welfare network , Hospitals , mental health and addictions network of care at the management and therapeutic plan. Practice implemented : The Catalan Department of Health , through the Mental Health and Addictions Master Plan ( PDSMiA ) and the Chronicity Prevention and Care Program ( PPAC ) has established the use of the Criteria of Chronic Patient ( broader concept of SMD ) and the Criteria for Complex Chronic Patient ; This last concept includes physical comorbities and some social conditions and needs ; after the results obtained by the Analysis Division of the Demand and Activity. Catalan Health Service have accorded to use this taxonomy in the national register system ; At, the moment, following the personal health card for the all Catalan population , we got data from 10.121.939 registered persons of wich 7.610.154 milions cards are from living people ( the Catalan population ) . The robust health registration catalan system is the key to make the results reliables and feasible.

Improving Patient Care Chronic Complex: Sub-Acute Care Unit

Introduction: The increasing ageing population has led to a proportional increase of people with chronic diseases, which has required implementing alternative models to conventional hospitalization in order to be able to respond. Patients with chronic diseases which present imbalance that require hospital care without complex diagnostic technology can be treated in less intensive intern units.The unit of sub-acute care (US) Health of Vallparadís (SSV) is a comprehensive, integral and cross-cutting assistive medical facility of intermediate hospitalization that was created at the end of 2012 within the framework of "Chronic patient care program of Mútua Terrassa" (PAPCMT). The ultimate goal of the program is to improve the chronic patient care complex (PCC) and MACA in the context of comprehensive and integrated care, reducing the frequency of emergency unit visits, unnecessary acute hospitals admissions, with a broader focus on the disease, geared to the person from a holistic perspective.Objective: Description of the general characteristics of the sub-acute care of Vallparadís Healthcare, as well as their assistance activity since the creation of the unit (November 2012-September 2015).Methodology: The US of SSV currently has 14 beds. It offers medical care 24 hours a day, 7 days a week.The healthcare model was initially based on offering an alternative for chronic unstable patient care in the home, later adding the patient in the process from the Hospital Universitari Mútua Terrassa emergency service.The functional plan of the unit defines inclusion and exclusion criteria, inner workings, circuits and flows of patients, relations with the chronic functional unit (CFU) of Mútua Terrassa and tracking indicators that are evaluated on a quarterly basis.Outcomes: Since the start of the activity in September 2015, 567 patients have been admitted, 66.7% from home at the request of the UFC, 29.3% from emergency facilities, and 4% from other sources.The most frequent diagnosis have been ICC (33.5%), COPD (25.04%), pneumonia (16.1%) and ITU (5.8%).There have been a total of 557 discharges. The average stay has been 10.19 days, with a rate of readmissions within 30 days of 4.5% and a mortality rate of 8.6%. Patients have returned home in 78% of cases, 8% were sent to acute hospital, and 5% to socio-sanitari services.A user satisfaction survey that assesses a global item, resulted in a score of 3.64 over 4. The admissions which didn’t come from the emergency services, valued not having to go through this service as very satisfactory in 88% of cases (3.88 over 4).Conclusions: The use of SSV has been consolidated as intermediate care hospitalization service within the PAPCMT assistance network.The results are satisfactory, with a high rate of discharge and low mortality rates, transfer to other services and readmissions. The satisfaction perceived by the patient is very high, indicating the quality of care.The management parameters of the unit show a correct internal functioning and good coordination with the other health resources involved in the attention within PCC, basically with the chronic functional unit of primary care and the hospital emergency services.

A person centred model for people with complex care needs

It is well known in the literature how the modern health and care systems are being oriented to launch and develop national strategies to construct and build a more comprehensive system for the people with health and social care Most of Chronic Care programs have been introduced proactive care management for this vulnerable population who are causing high utilization of high cost services. However a new Integrated health and social care have been introduced in some countries and regions and there is a need of identifying these populations at risk with new and well accepted criteria and new care approaches in the field. This workshop will combine both the and implementation in related to proactive management of people with complex care needs from a joint health and social care perspective. 2 or 3 countries will be invited to explain main strategies and real implementation examples which could be easily escalated. An additional overview of Walter Wodchis as international expert and reviewer of different international national or regional best practices will be incorporated. We will introduce different issues related to - Earlier work of complex chronic health needs during implementation of Chronic Care programs. Some part of this work has started some time ago and experience of some yers could be - Evolution from the “complex health needs” toward a “complex health and social care needs” approach. New approaches to identify criteria related to complex social care needs will be explored especially related to the social care area. ·International overview of the most recognized innovative experience related to care for people with complex health and social care needs - Terminology required to talk properly about complexity: complexity, complex care needs, multimorbidity, complex health and social care needs,...? - Complex care in practice explaining which strategy is being developed to take care of people with complex health and social care needs from an “individual, team and territorial (county)” perspective - ICT developments to support work with different organizations and professionals who work collaboratively to manage people under a person centred model: introduction of Key Information Summary or Individual Intervention Plans to be shared by all organizations and professionals under a 24/7 scheme and other strategies - Evaluation of complex care strategy It would be introduced 2 or maybe 3 experiences and an additional international overview: - Catalonia and Scotland will talk about both policy and implementation in practice models which have priorised care approach - Walter Wodchis from Intitit oof Healt Policy, Management and Evaluation at University of Toronto speak about the most promising and innovative world experiences related to complex care (Walter Wodchis is co-author of the June issue of IJIC publishing 7 study cases related to complexity), showing lessons about these experiences and reccommendations for countries and regions developing and implementing Integrated Care for people with complex health and social care needs. This workshop will offer a combination of policy and implementation in practice issues and additionally an overview of the best practices in the world related to complex care

Observational study of the impact of an individualized multidisciplinary chronic care program for hip and knee osteoarthritis treatment on willingness for surgery

To determine the impact of an osteoarthritis-specific multidisciplinary conservative care program (OACCP) on willingness for surgery (WFS) and to identify changes and factors in our cohort that influence and predict willingness for surgery. Consecutive OACCP participants with hip or knee OA, with WFS (willing, unsure or unwilling) data for at least two appointments were included. The proportions of unwilling versus willing/unsure patients at baseline and last appointment were compared using McNemar's test. Logistic regression was used to analyze baseline age, gender, main language, educational status, living situation, number of comorbidities, index joint, non-index joint osteoarthritis, completion of program, baseline and change in pain, function, depression, body mass index and 6-min walk test (6MWT) for association with changing WFS. At baseline 203/409 were unwilling for surgery while by final appointment 234/409 were unwilling (P = 0.002). Of the 206 initially willing/unsure participants, 63/206 (30.6%) became unwilling by final appointment. Index joint, completion of program, baseline and change in pain, self-reported function and 6MWT were independently associated with becoming unwilling. Final model from multivariate logistic regression analysis regarding becoming unwilling included baseline pain (P < 0.001), change in pain (P < 0.001), completion of program (P < 0.001) and age (P = 0.004). A conservative OA-specific treatment program that improves pain and function can reduce willingness for surgery among participants with hip or knee OA. The strongest determinants of this reduction in willingness were baseline and change in pain, completion of the program and participant age.

Targeting Gaps in the Quality of Care for Patients with Diabetes in Community Chronic Care Programs

To evaluate strengths and gaps in the care offered for chronic diseases in the community health centres (Centres de santé et de Service Sociaux [CSSS]) of the Eastern Townships (Québec) and design a new integrated program; the objective of this study was to determine the technical quality of care for diabetes.

呼吸ケア認定看護師（仮称）制度の発足に向けて

呼吸ケア認定看護師（仮称）制度の発足に向けて

Adapting HIV patient and program monitoring tools for chronic non-communicable diseases in Ethiopia.

BackgroundChronic non-communicable diseases (NCDs) have become a huge public health concern in developing countries. Many resource-poor countries facing this growing epidemic, however, lack systems for an organized and comprehensive response to NCDs. Lack of NCD national policy, strategies, treatment guidelines and surveillance and monitoring systems are features of health systems in many developing countries. Successfully responding to the problem requires a number of actions by the countries, including developing context-appropriate chronic care models and programs and standardization of patient and program monitoring tools.MethodsIn this cross-sectional qualitative study we assessed existing monitoring and evaluation (M&E) tools used for NCD services in Ethiopia. Since HIV care and treatment program is the only large-scale chronic care program in the country, we explored the M&E tools being used in the program and analyzed how these tools might be adapted to support NCD services in the country. Document review and in-depth interviews were the main data collection methods used. The interviews were held with health workers and staff involved in data management purposively selected from four health facilities with high HIV and NCD patient load. Thematic analysis was employed to make sense of the data.ResultsOur findings indicate the apparent lack of information systems for NCD services, including the absence of standardized patient and program monitoring tools to support the services. We identified several HIV care and treatment patient and program monitoring tools currently being used to facilitate intake process, enrolment, follow up, cohort monitoring, appointment keeping, analysis and reporting. Analysis of how each tool being used for HIV patient and program monitoring can be adapted for supporting NCD services is presented.ConclusionGiven the similarity between HIV care and treatment and NCD services and the huge investment already made to implement standardized tools for HIV care and treatment program, adaptation and use of HIV patient and program monitoring tools for NCD services can improve NCD response in Ethiopia through structuring services, standardizing patient care and treatment, supporting evidence-based planning and providing information on effectiveness of interventions.

Chronic case management: Clinical governance with cost reductions.

With increasing global impact of chronic degenerative non-communicable diseases (CDNCD), multidisciplinary chronic disease management care programs (CDMCP) come as a solution to improve the quality of patients care. We conducted a cross-sectional epidemiologic prospective cohort study with data comparing a group of patients monitored by a CDMCP with subjects without CDMCP care, from 2010 to 2012. The patients monitored in this program were selected because they presented CDNCD with frequent hospitalization and/or emergency care in the year prior to study selection. Also, the patients could be referred to the program by their physicians and/or other programs such as HomeCare or family medicine. All costs related to the program were included and compared with the costs of users with the same epidemiological profile who opted for not participating in the CDMCP. We analyzed data from 1,256 cases, including 639 (51%) men and 617 (49%) women. The mean age was 56.99 years and 73% were older than 50 years. There was a prevalence of 34% (428) cases with ischemic heart disease (myocardial infarction and stroke) and 17% (210) with neoplasms. The cases studied showed a reduction of 79% in the number of days of hospitalization compared with the cases without CDMCP monitoring. The average reduction of total costs (hospitalizations, emergency room visits and/or disease complications) was 31.94%, with average reduction of 8.36% in monthly costs. Multidisciplinary monitoring carried out by CDNCD patient management programs can reduce hospitalizations, emergency room visits and complications, positively impacting the costs with health care.

The Catalonia WHO Demonstration Project of Palliative Care: Results at 25 Years (1990–2015)

In 2015, the World Health Organization (WHO) Demonstration Project on Palliative Care in Catalonia (Spain) celebrated its 25th anniversary. The present report describes the achievements and progress made through this project. Numerous innovations have been made with regard to the palliative care (PC) model, organization, and policy. As the concept of PC has expanded to include individuals with advanced chronic conditions, new needs in diverse domains have been identified. The WHO resolution on “Strengthening of palliative care as a component of comprehensive care throughout the life course,” together with other related WHO initiatives, support the development of a person-centered integrated care PC model with universal coverage. The Catalan Department of Health, together with key institutions, developed a new program in the year 2011 to promote comprehensive and integrated PC approach strategies for individuals with advanced chronic conditions. The program included epidemiologic research to describe the population with progressive and life-limiting illnesses. One key outcome was the development of a specific tool (NECPAL CCOMS-ICO©) to identify individuals in the community in need of PC. Other innovations to emerge from this project to improve PC provision include the development of the essential needs approach and integrated models across care settings. Several educational and research programs have been undertaken to complement the process. These results illustrate how a PC program can respond and adapt to emerging needs and demands. The success of the PC approach described here supports more widespread adoption by other key care programs, particularly chronic care programs.

Users' Attitudes Towards Personal Health Records: A Cross-Sectional Pilot Study.

Prevention and management of chronic conditions is a priority for many healthcare systems. Personal health records have been suggested to facilitate implementation of chronic care programs. However, patients' attitude towards personal health records (PHRs) can significantly affect the adoption rates and use of PHRs. to evaluate the attitude of patients with Type II diabetes towards using a PHR to manage their condition. We used a cross-sectional exploratory pilot study. Fifty-four (54) patients used a PHR to monitor and record their blood glucose levels, diet, and activities for 30 days, and to communicate with their clinicians. At the end of the study, patients responded to a survey based on three constructs borrowed from different technology acceptance frameworks: relative advantage, job fit, and perceived usefulness. A multivariate predictive model was formed using partial least squaring technique (PLS) and the effect of each construct on the patients' attitude towards system use was evaluated. Patients also participated in a semi-structured interview. We found a significant positive correlation between job fit and attitude (JF → ATT = +0.318, p<0.01). There was no statistical evidence of any moderating or mediating effect of other main constructs or any of the confounding factors (i.e., age, gender, time after diagnosed) on attitude. The attitude of patients towards using PHR in management of their diabetes was positive. Their attitude was mainly influenced by the extent to which the system helped them better perform activities and self-manage their condition.

Psychological Traits in Patients Waiting for Total Knee Arthroplasty. A Cross-sectional Study

BackgroundTo determine the prevalence of psychiatric distress in an Australian patient population waiting for total knee arthroplasty and to assess the associations between psychological distress and other baseline characteristics. MethodsThis is a cross-sectional study of prospectively collected data from patients with knee arthritis participating in the New South Wales Osteoarthritis Chronic Care Program. Participants were divided into 2 groups based on the Depression Anxiety and Stress Score. The prevalence of psychological distress was compared to reported prevalence in the Australian community. Between-group comparisons of a number of variables were made, including demographic and socioeconomic data, health and psychiatric data, patient-reported knee and quality-of-life scores, and measured function. ResultsData from 3103 patients were available and 2809 patients were eligible for inclusion, with 1740 (62%) females. Mean patient age was 68 years, and mean body mass index was 33.8. We found 753 (26.8%, standard deviation: 0.44) of participants reported psychological distress. Those reporting distress were more likely to be female (P = .025), younger (66.6 vs 68.8 years, P < .001), with a higher body mass index (34.5 vs 32.7, P < .001), and had more comorbidities (3.4 vs 2.8, P < .001). The distressed group had significantly worse knee pain (visual analog scale: 7.1 vs 6.2, P < .001; Knee Injury and Osteoarthritis Score pain component: 28.9 vs 41.2, P < .001), knee function, and general quality-of-health scores (P < .001). ConclusionPsychological health is an important and often overlooked predictor of severity of symptoms and dysfunction in patients with knee arthritis. As it can affect the outcome for surgery, psychological health should be better assessed and treated before surgery to help reduce preoperative dysfunction and improve postoperative outcomes of total knee arthroplasty.

Strengths of primary healthcare regarding care provided for chronic kidney disease.

ABSTRACTObjective: to assess the structure and results obtained by the "Chronic Renal Patients Care Program" in a Brazilian city. Method: epidemiological, cross-sectional study conducted in 14 PHC units and a secondary center from 2010 to 2013. The Donabedian Model was the methodological framework used. A total of 14 physicians, 13 supervisors, and 11 community health agents from primary healthcare were interviewed for the assessment of structure and process and 1,534 medical files from primary healthcare and 282 from secondary care were consulted to assess outcomes. Results: most units lacked sufficient offices for physicians and nurses to provide consultations, had incomplete staffing, and most professionals had not received proper qualification to provide care for chronic renal disease. Physicians from PHC units classified as capable more frequently referred patients to the secondary care service in the early stages of chronic renal disease (stage 3B) when compared to physicians of units considered not capable (58% vs. 36%) (p=0.049). Capable PHC units also more frequently presented stabilized glomerular filtration rates (51%) when compared to partially capable units (36%) and not capable units (44%) (p=0.046). Conclusion: patients cared for by primary healthcare units that scored higher in structure and process criteria presented better clinical outcomes. Objective: to identify the coping strategies of family members of patients with mental disorders and relate them to family member sociodemographic variables and to the patient's clinical variables. Method: this was a descriptive study conducted at a psychiatric hospital in the interior of the state of São Paulo, with 40 family members of hospitalized patients over the age of 18, and who followed the patient before and during hospitalization. We used tools to characterize the subjects and the Folkman and Lazarus Inventory of Coping Strategies. Results: the coping strategies most often used by family members were social support and problem solving. Mothers and fathers used more functional strategies (self-control p=0.037, positive reappraisal p=0.037, and social support p=0,021). We found no significant differences between the strategies and other variables examined. Conclusion: despite the suffering resulting from the illness of a dear one, family members make more use of functional strategies, allowing them to cope with adversities in a more well-adjusted way.

Substitution scenario in follow-up of chronic cancer patients in primary care: prevalence, disease duration and estimated extra consultation time.

The incidence of cancer as well as survival rates for it are increasing. It is debated whether care in the chronic phase of cancer can be positioned in primary care due to doubts about capacity and workload. To estimate GPs' extra consultation time if they assume responsibility for the care in the chronic phase of cancer. Retrospective cohort study. Estimation of extra consultation time by quantifying prevalence, incidence, survival, number of chronic cancer patients, current practice contacts and registration of risk factors in patients with all types of cancers. The most prevalent types of cancer (with 5-year survival rates) are as follows: breast cancer (91.5%), colorectal cancer (63.8%), prostate cancer (78.3%), melanoma (91.9%) and bladder and urinary tract cancer (77.3%). Primary care practices include ~32 chronic cancer patients, with a potential extra consultation time of ~19 hours per year per 1000 patients. One-third (35%) are already in a chronic disease management programme and 57% were diagnosed >5 years ago. Registration of risk factors for cancer is incomplete, but of better quality when comorbidity is present. Numbers of chronic cancer patients and possible time investment by primary care professionals in the case of a substitution scenario should not be a limiting factor for transition of follow-up from secondary to primary care, as most of the patients were diagnosed >5 years ago and a large proportion of these patients are already monitored in an existing chronic care programme.

Measured outcomes of chronic care programs for older adults: a systematic review.

BackgroundWagner’s Chronic Care Model (CCM), as well as the expanded version (ECCM) developed by Barr and colleagues, have been widely adopted as frameworks for prevention and management of chronic disease. Given the high prevalence of chronic illness in older persons, these frameworks can play a valuable role in reorienting the health care system to better serve the needs of seniors. We aimed to identify and assess the measured goals of E/CCM interventions in older populations. In particular, our objective was to determine the extent to which published E/CCM initiatives were evaluated based on population, community, system and individual-level outcomes (including clinical, functional and quality of life measures).MethodsWe conducted a systematic search of the Science Citation Index Web of Knowledge search tool to gather articles published between January 2003 and July 2014. We included published CCM interventions that cited at least one of the fundamental papers that introduced and described the CCM and ECCM. Studies retained for review reported evaluations of senior-focused E/CCM initiatives in community-based settings, with the topic of “older adults” OR senior* OR elder* OR geriatric OR aged. The resulting 619 published articles were independently reviewed for inclusion by two researchers. We excluded the following: systematic reviews, meta-analyses, descriptions of proposed programs, and studies whose populations did not focus on seniors.ResultsWe identified 14 articles that met inclusion criteria. Studies used a wide range of measures, with little consensus between studies. All of the included studies used the original CCM. While a range of system-level and individual patient outcomes have been used to evaluate CCM interventions, no studies employed measures of population or community health outcomes.ConclusionsFuture efforts to test E/CCM interventions with seniors would be aided by more consistent outcome measures, greater attention to outcomes for the caregivers of older persons with chronic illness, and a greater focus on population and community impacts.

Incorporating patient preferences and priorities into end-of-life care.

41 Background: Patients with advanced illness often face painful conversations and difficult decisions. A program was deployed to help patients identify, communicate, and incorporate their personal preferences and priorities into decisions about their care. The program was assessed by measuring movement along the readiness for change continuum. Methods: Patients residing in the home and participating in a chronic care program were referred by their case managers based on clinical conditions and whether the patient appeared to be in their last 12 months of life. Counseling sessions with patients or family caregiver/s were designed to move participants toward the following actions: be fully informed about their medical situation, describe their detailed quality of life priorities, articulate a self-defined medical decision making process, effectively communicate to their family and physicians, and implement and repeat the aforementioned steps. After 5 months (Sept-2014 to Feb-2015), movement along the readiness for change continuum (pre-contemplation, contemplation, preparation, action, maintenance, and advocacy) was reported. Results: Of the 427 patients referred, 33 could not be reached, 116 were ineligible, 50 declined or did not engage. Of the 228 participants, 191 (84%) moved at least one step in readiness for change continuum over the 5-month period. In Nov-2014, 13% of participants were in action, maintenance, or advocacy, which increased to 19% by Feb-2015. The largest observed movement to action, maintenance, or advocacy was in defining quality of life priorities: 2% Nov-2014 to 21% Feb-2015. The least movement to action, maintenance, or advocacy was observed in articulating a self-defined medical decision making process: 3% Nov-2014 to 16% Feb-2015. Case managers reported discomfort in referring members based on their assessment of length of life. Early surveys show high levels of satisfaction. Conclusions: A very high percentage of patients progressed in incorporating their preferences and priorities into end of life care as measured by the readiness to change continuum. This program is currently expanding and the referral process is changing from case manager to algorithm based identification referrals.

Chronic and integrated care in Catalonia.

The Chronicity Prevention and Care Programme set up by the Health Plan for Catalonia 2011-2015 has been an outstanding and excellent opportunity to create a new integrated care model in Catalonia. People with chronic conditions require major changes and transformation within the current health and social system. The new and gradual context of ageing, increase in the number of chronic diseases and the current fragmented system requires this transformation to be implemented. The Chronicity Prevention and Care Programme aims to implement actions which drive the current system towards a new scenario where organisations and professionals must work collaboratively. New tools should facilitate this new context- or work-like integrated health information systems, an integrative financing and commissioning scheme and provide a new approach to virtual care by substituting traditional face-to-face care with transfer and shared responsibilities between patients, citizens and health care professionals. It has been observed some impact reducing the rate of emergency admissions and readmission related to chronic conditions and better outcome related to better chronic disease control. Some initiative like the Catalan Expert Patient Program has obtained good results and an appropriate service utilization. The implementation of a Chronic Care Program show good results but it is expected that the new integrated health and social care agenda could provoke a real change and transformation. Some of the results related to better health outcomes and a decrease in avoidable hospital admissions related to chronic conditions confirm we are on the right track to make our health and social system more sustainable for the decades to come.

Assessment of a chronic care programme in Girona (CRONIGICAT)

Introduction: The Programme for Prevention and Care of Chronic Illness in Girona CRONIGICAT aims to provide sustainable, integrated, quality care to chronic patients, targeted levels of care and interventions, and collaboration with other healthcare providers and social services. CRONIGICAT emerged during 2011 in the Girona Primary Care Region of the Institut Catala de la Salut as a result of the Health Plan 2011-2015 by the Department of Health of the Generalitat de Catalunya (Spain), which aimed to achieve a more chronic care oriented health care system. Short description of practice change implemented: CRONIGICAT includes a total of 20 different projects strategically related to the integration of care, continuity with social services, adapting the organization to the needs of chronic patients, patient involvement and self-care, prevention and health promotion, technological innovation, professional development and research. Aim and theory of change: To determine the usefulness and viability of a chronic care programme. CRONIGICAT has acted as a catalyst for a self-directed shift to a better chronic care model and has identified areas for improvement. International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-116939 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 Targeted population: A population of approximately 500,000 people registered in 26 primary care teams (PCT). Stakeholders: 7 hospitals and 76 nursing homes Timeline: 2011-present Highlights: Design: Cross-sectional descriptive study with qualitative and quantitative evaluation. Main measures: The degree of development of the programme, consensus indicators for chronic care proposed by the policy maker, the Department of Health of the Generalitat de Catalunya, and the Assessment of Readiness for Chronicity in Health Care Organisations (ARCHO/IEMAC) tool. Outcomes: • Evaluation of the degree of development: 75% of projects were partially or fully implemented. • Improvement trends were found in the consensus indicators for process (e.g. patients contacted 48 hours after hospital discharge, population included in chronic care programmes). • Slight decline in the consensus indicators for effectiveness (e.g. readmissions, mean length of hospital stay, avoidable hospital admissions, medicines expenditure, number of emergency appointments, and mortality). • The dimensions receiving the highest scores on the ARCHO/IEMAC tool were those evaluating information systems and clinical decision support, while those receiving the lowest scores were community health and self-care. Comments on sustainability: CRONIGICAT is sustainable in its implementation as all actions and projects are integrated within routine clinical practice. No additional resources are required for evaluation as the consensus indicators used are already compiled by the Department of Health. Comments on transferability: Implementation of projects directly focused on chronic patients carry a high degree of transferability of the actions designed. Conclusions: CRONIGICAT is useful, viable and sustainable. Discussions: Evaluation of a health care program can prove complex and it must take into account qualitative and quantitative aspects. Lessons learned: The need for integration within the health care system of the practical implementation of chronic care projects and their evaluation to allow the use of existing resources, and the involvement of all stakeholders towards common goals.

Impelementation and assessment of social and health local partnerships for integrated care in Catalonia

Integrated health and social care is emerging as a trending area of interest in the governmental policy agenda in Europe. Most governments are facing great challenge to overcome barriers to facilitate Integrated Care between health and social services. Integrated care has been in the health policy agenda but new challenges should be coped regarding the incorporation of social services, especially for the persons with complex chronic condition with health and social needs. Although this integration improves both health and social care systems, it is a difficult task to get both groups to work together due to different factors. Early this year, the Government of Catalonia issued a new Integrated Health and Social Care Plan to promote, lead and participate in the transformation of the social and health care model to achieve person-centred full integrated care and so to deliver holistic care to high-cost, high-need citizens in order to help to lower costs, enhance quality of care, and improve outcomes. During this session it will be shortly presented the journey from the Chronic Condition Prevention and Care Program to the new Integrated Health and Social Care Plan in Catalonia, but it’s going to be focused specifically on the implementation strategy through Local Partnerships. 9 of this Local Partnerships Implementation Projects have been assessed by the Catalan Agency for Quality in Health and Assessment so we can present and discuss the results of this evaluation about: Structure and functioning of experiences identified that include a collaborative model (mainly: social services and primary care services). Barriers and facilitators of collaborative models. Perceived benefits and expected results and areas for improvement. Propose a conceptual model of assessment and possible common pool of indicators 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117003 – http://www.ijic.org/

Interim analysis: An interdisciplinary team approach in facilitating weight reduction and improving function for people with knee or hip osteoarthritis. The Osteoarthritis Chronic Care Program at Royal North Shore Hospital

AbstractAimInterim analysis of the Osteoarthritis Chronic Care Program at the Royal North Shore Hospital was conducted in order to determine (i) effectiveness of programme to facilitate reductions in weight and waist circumference and improvements in pain, function and osteoarthritis‐related outcomes and (ii) whether reductions in weight or waist circumference predict pain, functional and osteoarthritis‐related outcomes.MethodsParticipants with knee or hip osteoarthritis at baseline (n = 265), weeks 12 (n = 164) and 26 (n = 88) were followed. Primary outcomes were weight and waist circumference. Secondary outcomes included visual analogue scale for pain, timed up and go, 6‐minute walk test, knee injury/hip dysfunction and osteoarthritis outcome score.ResultsMean absolute and percent weight loss, waist circumference and body mass index significantly reduced from baseline at both 12 and 26 weeks. Improvements in pain (P &lt; 0.001), timed up and go (P &lt; 0.001) and 6‐minute walk test (P &lt; 0.001) were statistically significant in participants with knee osteoarthritis; however, only improvements in timed up and go and 6‐minute walk test were clinically relevant. Weight was not associated with any secondary outcomes except knee injury and osteoarthritis outcome score pain subscale at 12 weeks. Participants with knee osteoarthritis on average experienced 0.96 cm less pain on the visual analogue scale and walked 25.7 m more in the 6‐minute walk test than participants with hip osteoarthritis at 12 weeks which was statistically significant.ConclusionsThe programme assisted participants in promoting weight loss and those with knee osteoarthritis improved clinically in mobility and walking capacity by 26 weeks. Complete data set is required to validate these findings.