Integrated care services: lessons learned from the deployment of the NEXES project
Carme Hernández, Albert Alonso, Judith Garcia-Aymerich, Anders Grimsmo, Theodore Vontetsianos, Francesc García Cuyàs, Anna Garcia Altes, Ioannis Vogiatzis, Helge Garåsen, Laura Pellise, Leendert Wienhofen, Isaac Cano, Montserrat Meya, Montserrat Moharra, Joan Ignasi Martinez, Juan Escarrabill, Josep Roca, Carme Hernández, Albert Alonso, Judith Garcia-Aymerich, Anders Grimsmo, Theodore Vontetsianos, Francesc García Cuyàs, Anna Garcia Altes, Ioannis Vogiatzis, Helge Garåsen, Laura Pellise, Leendert Wienhofen, Isaac Cano, Montserrat Meya, Montserrat Moharra, Joan Ignasi Martinez, Juan Escarrabill, Josep Roca
Abstract
Objectives: To identify barriers to deployment of four articulated Integrated Care Services supported by Information Technologies in three European sites. The four services covered the entire spectrum of severity of illness. The project targeted chronic patients with obstructive pulmonary disease, cardiac failure and/or type II diabetes mellitus.
Setting: One health care sector in Spain (Barcelona) (n = 11.382); six municipalities in Norway (Trondheim) (n = 450); and one hospital in Greece (Athens) (n = 388).
Method: The four services were: (i) Home-based long-term maintenance of rehabilitation effects (n = 337); (ii) Enhanced Care for frail patients, n = 1340); (iii) Home Hospitalization and Early Discharge (n = 2404); and Support for remote diagnosis (forced spirometry testing) in primary care (Support) (n = 8139). Both randomized controlled trials and pragmatic study designs were combined. Two technological approaches were compared. The Model for Assessment of Telemedicine applications was adopted.
Results: The project demonstrated: (i) Sustainability of training effects over time in chronic patients with obstructive pulmonary disease (p < 0.01); (ii) Enhanced care and fewer hospitalizations in chronic respiratory patients (p < 0.05); (iii) Reduced in-hospital days for all types of patients (p < 0.001) in Home Hospitalization/Early Discharge; and (iv) Increased quality of testing (p < 0.01) for patients with respiratory symptoms in Support, with marked differences among sites.
Conclusions: The four integrated care services showed high potential to enhance health outcomes with cost-containment. Change management, technological approach and legal issues were major factors modulating the success of the deployment. The project generated a business plan to foster service sustainability and health innovation. Deployment strategies require site-specific adaptations.
Keywords: case management; chronic disease; integrated health care systems; long-term care; telemedicine.
Figures
References
- World Health Organization (WHO) Innovative Care for Chronic Conditions. Building Blocks for Action Global Report. 2002. [cited 2015 Jan 8]. Available from: .
- Murray CJ, Lopez AD. Measuring the global burden of disease. The New England Journal of Medicine. 2013;369:448–57.
- van der Klauw D, Molema H, Grooten L, Vrijhoef H. Identification of mechanisms enabling integrated care for patients with chronic diseases: a literature review. International Journal of Integrated Care. 2014;14:e024. Available from: .
- Epping-Jordan JE, Galea G, Tukuitonga C, Beaglehole R. Preventing chronic diseases: taking stepwise action. Lancet. 2005;366:1667–71.
- World Health Organization (WHO) Preparing a health care work force for the 21 st century. The challenge of chronic conditions. 2011. [cited 2015 Jan 8]. Available from: .
- Roca J, Garasen HM, Grimsmo A, Meya M, Alonso A, Gorman J, et al. NEXES: supporting healthier and independent living for chronic patients and elderly. 2013. [cited 2015 Jan 8]. Available from: .
- Health Plan for Catalonia 2011–2015. 2012. [cited 2015 Jan 8]. Available from: .
- Heimly V, Hygen J. The Norwegian coordination reform and the role of electronic collaboration. Journal of Health Informatics. 2011;6(4):e29.
- Casas A, Troosters T, Garcia-Aymerich J, Roca J, Hernandez C, Alonso A, et al. Integrated care prevents hospitalisations for exacerbations in COPD patients. The European Respiratory Journal. 2006;28:123–30.
- Hernandez C, Casas A, Escarrabill J, Alonso J, Puig-Junoy J, Farrero E, et al. Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients. The European Respiratory Journal. 2003;21:58–67.
- Allweyer T. BPMN 2.0: introduction to the standard for business process modeling: books on demand GmbH. Norderstedt. 2010. [cited 2015 Jan 8]. Available from: .
- Barberan-Garcia A, Vogiatzis I, Solberg HS, Vilaro J, Rodriguez DA, Garasen HM, et al. Effects and barriers to deployment of telehealth wellness programs for chronic patients across 3 European countries. Respiratory Medicine. 2014;108:628–37.
- ATS statement: guidelines for the six-minute walk test. American Journal of Respiratory and Critical Care Medicine. 2002;166:111–17.
- Ferrer M, Alonso J, Prieto L, Plaza V, Monso E, Marrades R, et al. Validity and reliability of the St George's respiratory questionnaire after adaptation to a different language and culture: the Spanish example. The European Respiratory Journal. 1996;9:1160–66.
- Vilagut G, Ferrer M, Rajmil L, Rebollo P, Permanyer-Miralda G, Quintana JM, et al. The Spanish version of the short form 36 health survey: a decade of experience and new developments. Gaceta Sanitaria. 2005;19:135–50.
- Vilaro J, Gimeno E, Sanchez FN, Hernando C, Diaz I, Ferrerc M, et al. Daily living activity in chronic obstructive pulmonary disease: validation of the Spanish version and comparative analysis of 2 questionnaires. Medicina Clínica (Barcelona) 2007;129:326–32.
- Burgos F. Impact of information and communication technologies on remote testing. University of Barcelona; 2013. Doctoral Thesis. [webpage on the internet]. [cited 2015 Jan 8]. Available from: .
- Mjolstad OC, Snare SR, Folkvord L, Helland F, Grimsmo A, Torp H, et al. Assessment of left ventricular function by GPs using pocket-sized ultrasound. Family Practice. 2012;29:534–40.
- Cano I. Predictive medicine for chronic patients in an integrated care scenario chronic obstructive pulmonary disease as use case. University of Barcelona; 2014. Doctoral Thesis. [cited 2015 Jan 8]. Available from: .
- Marrugat J, Vila J, Pavesi M, Sanz F. Estimation of the sample size in clinical and epidemiological investigations. Medicina Clínica (Barcelona) 1998;111:267–76.
- Kidholm K, Ekeland AG, Jensen LK, Rasmussen J, Pedersen CD, Bowes A, et al. A model for assessment of telemedicine applications: MAST. The International Journal of Technology Assessment in Health Care. 2012;28:44–51.
- SMART. Study on the legal framework for interoperable eHealth in Europe. 2007. [cited 2015 Jan 8]. Available from: .
- Quinn P, De Hert P. The patients’ rights directive -providing (some) rights to EU residents seeking healthcare in other Member States. Computer Law & Security Review. 2011/24/EU;27:497–502. doi: 10.1016/j.clsr.2011.07.010.
- Komisar H, Feder J, Ginsburg P. “Bundling” payment for episodes of hospital care: issues and recommendations for the new pilot program in medicare. Center for American Progress; 2011. [webpage on the internet]. [cited 2015 Jan 8]. Available from: .
- Burgos F, Disdier C, de Santamaria E, Galdiz B, Roger N, Rivera ML, et al. Telemedicine enhances quality of forced spirometry in primary care. The European Respiratory Journal. 2012;39:1313–18.
- Burgos F, Melia U, Vallverdú M, Velickovski F, Lluch-Ariet M, Caminal P, et al. Clinical decision support system to enhance quality control of spirometry using information and communication technologies. Journal of Medical Internet Research: Medical Informatics. 2014;2(2):e29. doi: 10.2196/medinform.3179.
- Marina N, Galdiz J.B, de Santamaria E. Estudio multicéntrico para el análisis de la efectividad de la telemedicina en programas de aseguramiento de la calidad de las espirometrías. Agencia de Evaluación de Tecnologías Sanitarias del País Vasco; 2012. [cited 2015 Jan 8]. Available from: .
- Evaluation of the first year of the Inner North West London Integrated Care Pilot. London: Nuffield Trust.-Imperial College; 2013. [cited 2015 Jan 8]. Available from: .
- Tinetti ME, Studenski SA. Comparative effectiveness research and patients with multiple chronic conditions. The New England Journal of Medicine. 2011;364:2478–81.
- Rouse WB. Health care as a complex adaptive system: implications for design and management. The Bridge. 2008;Spring:17–25.
- Integrated care and partnership working. The King′s Fund; 2014. [cited 2015 Jan 8]. Available from: . 2013.
- Hawkes N. Hospitals without walls. British Medical Journal. 2013;347:f5479.
- Vize R. Integrated care: a story of hard won success. British Medical Journal. 2012;344:e3529.
- Atkins D, Kupersmith J, Eisen S. The veterans affairs experience: comparative effectiveness research in a large health system. Health Affairs (Millwood) 2010;29:1906–12.
- McCreary L. Kaiser permanente's innovation on the front lines. Harvard Business Review. 2010;88:92, 94–7–126.
- True G, Butler AE, Lamparska BG, Lempa ML, Shea JA, Asch DA, et al. Open access in the patient-centered medical home: lessons from the Veterans Health Administration. Journal of General Internal Medicine. 2013;28:539–45.
- Steventon A, Bardsley M, Billings J, Dixon J, Doll H, Hirani S, et al. Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. British Medical Journal. 2012;344:e3874.
- Barabasi AL. Network medicine-from obesity to the “diseasome”. The New England Journal of Medicine. 2007;357:404–7.
- Bousquet J, Anto JM, Sterk PJ, Adcock IM, Chung KF, Roca J, et al. Systems medicine and integrated care to combat chronic noncommunicable diseases. Genome Medicine. 2011;3:43.
- Loscalzo J, Kohane I, Barabasi AL. Human disease classification in the postgenomic era: a complex systems approach to human pathobiology. Molecular Systems Biology. 2007;3:124.
- Busse R, Stahl J. Integrated care experiences and outcomes in Germany, the Netherlands, and England. Health Affairs (Millwood) 2014;33:1549–58.
- Advancing Care Coordination and Telehealth Deployment. 2013. [cited 2015 Jan 8]. Available from: .
- Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Anto JM. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax. 2006;61:772–778.
- Turan N, Kalko S, Stincone A, Clarke K, Sabah A, Howlett K, et al. A systems biology approach identifies molecular networks defining skeletal muscle abnormalities in chronic obstructive pulmonary disease. PLoS Comput Biol. 2011;7:e1002129.
- Better Breathing: A new model for continuous care of chronic patients. 2008. [cited 2015 Jan 8]. Available from: .
- Ferrer M, Alonso J, Prieto L, Plaza V, Monso E, Marrades R, et al. Validity and reliability of the St George's Respiratory Questionnaire after adaptation to a different language and culture: the Spanish example. Eur Respir J. 1996;9:1160–1166.
- Roca J, Garasen HM, Grimsmo A, Meya M, Alonso A, Gorman J, et al. NEXES: Supporting Healthier and Independent Living for Chronic Patients and Elderly. 2013. [cited 2015, Jan 8]. Available from: .
- Barberan-Garcia A, Vogiatzis I, Solberg HS, Vilaro J, Rodriguez DA, Garasen HM, et al. Effects and barriers to deployment of telehealth wellness programs for chronic patients across 3 European countries. Respir Med. 2014;108:628–637.
- Casas A, Troosters T, Garcia-Aymerich J, Roca J, Hernandez C, Alonso A, et al. Integrated care prevents hospitalisations for exacerbations in COPD patients. Eur Respir J. 2006;28:123–130.
- Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67:361–370.
- Vilagut G, Ferrer M, Rajmil L, Rebollo P, Permanyer-Miralda G, Quintana JM, et al. The Spanish version of the Short Form 36 Health Survey: a decade of experience and new developments. Gac Sanit. 2005;19:135–150.
- Hernandez C. The NEXES project. University of Barcelona; 2015. Deployment of Integrated Care Services for Chronic Patients Supported by Information and Communication Technologies. Doctoral Thesis.
- Activitat assistencial de la xarxa sanitaria de Catalunya.Conjunt minim basic de dades (CMBD). Generalitat de Catalunya. 2013. [cited 2015 Jan 8]. Available from:
- Pozo-Rodriguez F, Alvarez CJ, Castro-Acosta A, Melero MC, Capelastegui A, Esteban C, et al. Clinical audit of patients admitted to hospital in Spain due to exacerbation of COPD (AUDIPOC study): method and organisation. Arch Bronconeumol. 2010;46:349–357.
- Pozo-Rodriguez F, Lopez-Campos JL, Alvarez-Martinez CJ, Castro-Acosta A, Aguero R, Hueto J, et al. Clinical audit of COPD patients requiring hospital admissions in Spain: AUDIPOC study. PLoS One. 2012;7:e42156.
- Price LC, Lowe D, Hosker HS, Anstey K, Pearson MG, Roberts CM. UK National COPD Audit 2003: Impact of hospital resources and organisation of care on patient outcome following admission for acute COPD exacerbation. Thorax. 2006;61:837–842.
- Roberts CM, Ryland I, Lowe D, Kelly Y, Bucknall CE, Pearson MG. Audit of acute admissions of COPD: standards of care and management in the hospital setting. Eur Respir J. 2001;17:343–349.
- Burgos F. Impact of Information and Communication Technologies on Remote Testing. University of Barcelona; 2013. Doctoral Thesis. [webpage on the internet]. [cited 2015, Jan 8]. Available from: .
- Burgos F, Melia U, Vallverdú M, Velickovski F, Lluch-Ariet M, Caminal P, et al. Clinical Decision Support System to Enhance Quality Control of Spirometry using Information and Communication Technologies. JMIR Med Inform. 2014;2(2):e29. doi: 10.2196/medinform.3179.
- Marina MN, Lopez de Santa ME, Gutierrez A, Bayon JC, Garcia L, Galdiz JB. Telemedicine spirometry training and quality assurance program in primary care centers of a public health system. Telemed J E Health. 2014;20:388–392.
- Allweyer T. BPMN 2.0: Introduction to the Standard for Business Process Modeling: Books on Demand GmbH. Norderstedt. 2010. [cited 2015, Jan 8]. Available from: .
- Burgos F, Disdier C, de Santamaria E, Galdiz B, Roger N, Rivera ML, et al. Telemedicine enhances quality of forced spirometry in primary care. Eur Respir J. 2012;39:1313–1318.
- Castillo D, Guayta R, Giner J, Burgos F, Capdevila C, Soriano JB, et al. COPD case finding by spirometry in high-risk customers of urban community pharmacies: a pilot study. Respir Med. 2009;103:839–845.
- Kidholm K, Ekeland AG, Jensen LK, Rasmussen J, Pedersen CD, Bowes A, et al. A model for assessment of telemedicine applications: MAST. Int J Technol Assess Health Care. 2012;28:44–51.
- Advancing Care Coordination and Telehealth Deployment. 2013. [cited 2015 Jan 8]. Available from: .
Source: PubMed