Experiencia ProPCC o cómo crear un modelo de atención integrada en cronicidad liderada por equipos de Atención Primaria

The success of universal social and health systems in Europe confronts us with the challenge of how to respond to increasingly aging populations with high resource requirements. We see how multimorbidity (presence of various chronic diseases at the same time) is beginning to be the norm, and how fragility (condition of risk of disability and consumption of resources) is bursting into our agendas. Recently, the Covid-19 pandemic has highlighted the need for a change in the care model for the most vulnerable populations. This seems especially necessary in the group of patients classified as high need high cost where the consumption of resources, especially hospitals, skyrockets, as the health and social system does not adapt to health care requirements. In this entry we present our experience, of more than five years, of developing and evaluating a chronicity care program aimed at large consumers of resources in the northern metropolitan area of ​​Barcelona.

The integration of care to build the systems of the future.

In recent decades, the field of integrated care has been essential for the planning of health systems. The economic impact that the integration of services can have is usually linked to a strategy of organizational change and the way in which services are provided, always with a clinical approach aimed at adapting resources to each of the populations that require them. . . The various strategies internationally developed chronic care programs have focused on detecting the populations with the most morbidities and high consumption of resources, with the aim of adapting the care response in each territory. In Catalonia, chronicity planning is evolving towards strategies to enhance the integration of health and social services, with two premises to take into account:

• the centrality of Primary Care (PC) focused on the provision of services in the community, with a powerful vertical integration with the hospital, and
• the role of Social Services in guaranteeing horizontal integration and coverage of people’s needs.

The challenge of building a care model integrated into our environment.

With the accumulated advances of international reference models in chronicity, many derivatives of Chronic care model, The evidence advocates promoting PA in the community with intense interventions such as those of various american programs. In this sense, in 2018, in the Catalan Institute of Health We develop, through a specific Clinical Directorate of the North Metropolitan Territorial Managementa model of integration of chronic care focused on two population groups: frail older people (at risk of complications and resource consumption derived from loss of autonomy) and people with high health and social needs derived from their morbidities. chronic and advanced (complex chronic patients or patients diagnosed with advanced disease/s).

Figure 1. Planning strategy for care for populations with chronic conditions in the North Metropolitan Management, Institut Català de la Salut (2018-2024)

In the Badalona area, we had the opportunity to design a care model through the development of the Procommunity integration program for a Persones amb crhonicity coplexa (ProPCC MetroNord ICS Program), involving more than a hundred people including patients, caregivers and professionals. Having the participation of citizens helped us to dimension very well the reason for adapting the model and the reason for collaborative work in the provision of services: the common objective has been from day one to achieve person-centered care. of quality prioritizing care at home.

Once the clinical actions have been defined, we move on to consider organizational adaptations and the way services are provided. With the aim of enhancing the proactivity of PC in the community, without breaking with its inherent longitudinality, we implemented a multidisciplinary case management model with professionals from the Primary Care Teams themselves aimed at providing support to the referring teams in cases of discharges. . health and social needs. These teams work closely with a solid network of community teams, such as home hospitalization, home rehabilitation or home palliative care, as well as with the social services teams of each municipality. The multidisciplinary case management model was also adapted in the Hospital German Trias implementing an in-hospital case management unit of the Geriatrics Service, to provide support in decision-making and work for the adaptation of resources.

Figure 2. Community multidisciplinary case management model derived from the ProPCC Metropolitana Nord Program of the Institut Català de la Salut

Lessons learned and what the future holds

With the retrospective analysis of the first stage of implementation We have seen how an increase in proactivity in the provision of home services led by PCs has a powerful impact on reducing the consumption of hospital resources, a fact that entails a reduction of more than 40% in the costs linked to health visits. . These results are in line with the findings of other groups that advocate intensify monitoring in the community facilitating the optimization of resources and health results.

From our experience, we must highlight as the main barrier the difficulties in obtaining professional resources for the consolidation of these case management units during implementation. In chronic care, we must have teams that have time and space for decision-making, as well as multidisciplinary knowledge to individualize care. We have learned that we cannot make a change in the health care model without mobilizing specific resources to enhance already existing services – such as those linked to PC and community care – and without adapting interventions in higher risk stages, such as crises, transitions between care levels and entry into the end-of-life period (with a prominent role of hospital resources specialized in Geriatrics).

We see a future full of opportunities: on the one hand, to grow the model by adapting it to the realities of other territories; On the other hand, we have the challenge of improving the provision of community social resources, deepening horizontal health-social integration. Last but not least, we must continue to analyze the impact of new models on people’s experience. We cannot lose sight of the fact that the system of the future will only be able to adapt to people if it is built with the participation of all the actors involved, be they patients, caregivers, clinicians or planners.