This document summarizes information about the CONNECARE project, which aims to provide connected care for complex chronic patients in Lleida, Spain. The project focuses on improving communication between primary care and hospitals to better coordinate care for these patients. It develops a case management system using risk stratification and remote monitoring to prevent acute situations for complex chronic patients. The system includes self-management tools for patients. An initial study involved 28 complex chronic patients in Lleida to test the CONNECARE approach to integrated management across primary care and hospitals.
Connected Care for Complex Chronic Patients in Lleida
1. Connected Care for Complex
Chronic Patients in Lleida
Eloisa VARGIU, Juan Manuel FERNÀNDEZ, Felip MIRALLES
Mireia Massip, Gerard TORRES
Felix MICHEL, Florian MATTHES
2. Complex Chronic Patient
• 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
2
3. Complex Chronic Patient
• 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
3
6. Clinic or socio-familiar event
Frail patient that does not start to consume resources, yet
When is the right moment to act?
1
1
7. Clinic or socio-familiar event
Frail patient that does not start to consume resources, yet
At primary care: patient that has been already hospitalized at least once and go to
primary care for a control
When is the right moment to act?
1
1
2
2
8. Clinic or socio-familiar event
Frail patient that does not start to consume resources, yet
At primary care: patient that has been already hospitalized at least once and go to
primary care for a control
At the hospital: hospitalization of a patient that has already been hospitalized 1 or more
times
When is the right moment to act?
1
1
2
2
3
3
10. • 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
Underlying needs
• A work plan agreed among primary care doctors and
hospital staff (need of communication)
• Preventive actions at ambulatory level
11. 11
1. Improvement of communication and information flow between primary
care and hospital to work together
2. Remote monitoring of clinic variables and improvement of
communication among the professional team and the patient to prevent
acute situations
“All to one and better to anticipate problems”
The CONNECARE solution
20. Self-Management System
Profile / Settings
Notifications
Messages
Advices
Educational Material
System Notifications
Devices
configuration
21. CONNECARE in Lleida
21
Population: ≈ 400k people
Hospitals:
Hospital Universitari Arnau de Vilanova (HUAV)
Hospital Universitari de Santa Maria (HUSM)
≈ 500k office visits/year
≈ 14k admissions/year
Primary Care:
23 Primary Care centres (12 of them 24h)
1 Primary Care emergency centre
22. CONNECARE in Lleida
22
28 patients;
50% women;
Median (min-max) age 84 (55-95)
Median (min-max) Charlson 7 (2-10);
Median (min-max) LACE 14 (9-19)
Studies started on July 2018 in Lleida region focuses
on integrated management of:
CS1 - CCP with medical worsening
CS2 - CCP undergoing surgical procedures
Current situation:
1 case manager from the Hospital Santa Maria
31 hospital professionals
50 primary care professionals
CS1
29 patients;
59% women;
Median (min-max) age 75 (56-86)
Median (min-max) Charlson 4 (1-9)
CS2
23. CONNECARE @ICIC19
23
Poster 220
Poster 219
Poster 302
Overcoming Integration
Failure Through Negotiation
– A Workshop for Doers and
Planners CONNECARE: A
Bridge Over Troubled Waters
Workshop
Tuesday, April 2nd
14:00 – 15:30
5F
24. Thanks
Gràcies
This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 689802
Bedankt תודה
Grazie Danke
eloisa.vargiu@eurecat.org