Mariella Martini

Coordinator of HPH Emilia Romagna Regional Network

HealthPromoting Hospitals

PATHWAYS OF INTEGRATED CARE FOR PATIENTS AFFECTED BY HEART

FAILURE

(Ed Wagner, MacColl Institute for Healthcare Innovation)

Informed,ActivatedPatient

Prepared,Proactive

Practice Team

ProductiveInteractions

Community

Resourcesand Policies

Health System(Health Care Organization)

Self-ManagementSupport

Delivery SystemDesign

DecisionSupport

Clinical InformationSystems

TARGET: PATIENTS WITH- NEOPLASTIC PATHOLOGIES- RESPIRATORY FAILURE- CARDIAC DECOMPENSATION

THE PATIENT-PERSON:Decisions based on

weighted judgements(Illness Histories)

… as a method for:

- systematising ideas and actions (finding a way out of the confusion “caused

by complexity”, of the routine chaos)

- identifying measurable spaces ofefficiency (EBM) and effectiveness,

(translating the evidence into “practices”:GOOD PERFORMANCE)

- highlighting the “global” needs of the patient-person

- assigning indicators for monitoring

EFFECTIVENESSAND APPROPRIATENESS:

Decisions basedon scientific evidence(EBM-based decisions)

Evidence-based MedicineNarrative-based Medicine

PALLIATIVETREATMENT

…………………………

………………….

PRESENCE OF THE PROBLEM

IN-DEPTHDIAGNOSTICS

COMMUNICATION

DEFINITION OF PERSONALISED PROGRAMME.

SHARED (agreed)THERAPY PROGRAMME.

INTERACTIVE TREATMENT

INTERACTIVEMONITORING

* Is the diagnosis always informed?* To whom?* How and when?* Which family member is informed of the diagnosis?* Appropriate verbal (and other) language? * …………………………

* Am I the right professional figure?* Am I aware of my state of mind?* Do I possess the right resources to manage my emotions in this relationship?* …………….

* What is the structure and what are the internal relationships of the family?* Who is the reference figure within the family?* …………….

(PATIENT) PERSON

OPERATOR

FAMILY

A S S I S T A N C E P A T H as a useful model for considering not only clinical improvement but all other

dimensions as well

CURING THEDISEASE

CURING THESYSTEM

CURING THEILLNESS

Aims of the projectAims of the project

•To improve the organisation and quality of life of the patients with a more

effective and efficient integrated pathology management, preventing unnecessary hospitalisation or reducing the

length of stay

• To guarantee patient centrality To guarantee patient centrality (empowerment)

•To improve the appropriateness of To improve the appropriateness of the interventionsthe interventions

centering them on the results, in terms of improved clinical effectiveness but also closer response to patient

needs (not only E.B.M. but also patient life histories)

Working methodologyWorking methodology

Phase 1: analysis and development of diagnostic-therapeutic guidelines and organisational-

relational protocols/recommendations

Phase 2: preparation of theoretical path

Phase 3: training programmes for all professionals in the network dealing with Cardiac

Decompensation

Phase 4: start of experimentation

Phase 5: clinical audit to monitor the indicators

Working tools/1

Diagnostic-therapeutic guidelines and organisational-relational recommendations

Path flow-chart

Follow up sheet

Decompensated patient pathDecompensated patient pathPRESENCE OF SYMPTOMS 1ST

DIAGNOSIS

GENERAL PRACTITIONER

HOSPITAL

REFERRAL TO LOCAL / HOSPTIAL SPECIALIST FOR FURTHER INVESTIGATIONS

INVESTIGATIONS

  

 

DECOMPENSATIO

N

 

 

 

NO

NYHA I CLASS

NYHA II CLASS

NYHA III CLASS

NYHA IV CLASS

YES

GENERAL PRACTITIONER COMMUNICATES DIAGNOSIS (or repeats the information given by the

hospital/territorial doctor) AND EDUCATES THE PATIENT IN TERMS OF CORRECT LIFESTYLE, THE IMPORTANCE OF FOLLOWING THE THERAPY, AND

THE RECOGNITION OF SYMPTOMS

EARLY FOLLOW-UP

STABLE PATIENT

SENT TO GENERAL PRACTITIONER WITH DISCHARGE LETTER / SPECIALIST REPORT, COMPLETION OF

DECOMPENSATION SHEET AND INDICATION OF PROPOSED THERAPIES AND FOLLOW UP

STAYS IN CLASS I

GP and specialists

communicate by phone and internet

NYHA 1

POSSIBLE ADJUSTMENT OF

PHARMACOLOGICAL THERAPY

  

  

GP SETS THE THERAPY AND FOLLOW UP (sets the next stage at each check up and notes it on the follow up sheet)

NO YES

SPECIALIST CONSULT

SPECIALIST REPORT INDICATING ANY

MODIFICATION IN THE THERAPY AND FOLLOW UP

GENERAL PRACTITIONER COMMUNICATES

OUTCOME TO PATIENT AND ESTABLISHES

THERAPY AND FOLLOW-UP

ExampleExample

Working tools/2

Self-monitoring sheets paziente: -Weight control sheet-Blood pressure control sheet-Physical activity monitoring sheet-Pharmacological compliance monitoring sheet

Information booklet: given to patient at the time of diagnosis; strong educational impact, with little technical information

Recipe book: given to patient at the time of diagnosis. Includes recipes suited to the whole family

Making a “therapy deal” with the Making a “therapy deal” with the patient involves:patient involves:

correct communicationcorrect communication

education of patient and familyeducation of patient and family

control of the adherence to thecontrol of the adherence to thepharmacological and other pharmacological and other

types of therapytypes of therapy

Transferring clear, appropriate messages to the patient concerning his pathology and checking his level of understanding With the patient’s consent, transferring the same messages to her/his relatives and checking the level of understanding Not having inattentive, distracted or didactic attitudes Paying attention to the patient’s doubts, uncertainties and fears Understanding and managing any attitudes of resentment the patient may have towards usIT IS FUNDAMENTAL FOR ALL THE INVOLVED

PROFESSIONALS TO USE THE SAME LANGUAGE

Communicating the diagnosisCommunicating the diagnosis

Educating the patient/relatives

Initial education at the time of diagnosis (by GP or hospital doctor), with patient/relative training aimed at self-monitoring

Handing over information booklet

Handing over the recipe book

Continuous education by all the professionals involved in the path

Yearly meetings with experts (diet, physical fitness, psychological reactions to the illness and management of such reactions…)

Ask the patient if he has taken the prescribed medicines

Ask the relatives the same thing

Check the self-monitoring compliance sheet

Objectively assess the consumption of medicines

Check the expected effects of some pharmacological therapies

Investigate the low tolerance of particular medicines

Checking pharmacological compliance….

Checking the introduction

Checking the diuresis

Checking the diet in relation to any cardiovascular risk factors

Checking life style

Checking non-pharmacological

compliance means….

USEFUL TOOLS FOR MANAGING CHRONIC PATIENTS

Aspettative dell’utente Esperienza dell’utente

Selezione

Ingresso

Primo contatto

Prima risposta

Intervento

Revisione

Chiusura

Follow-up

Divisione1

Divisione3

Servizio2

Risultatiparziali

Risultato per

l’utente

Risultatiparziali

Risultatiparziali

Processo assistenziale (il percorsopercorso del cittadino all’interno dell’Azienda)

HospitalAspettative dell’utente Esperienza dell’utente

Selezione

Ingresso

Primo contatto

Prima risposta

Intervento

Revisione

Chiusura

Follow-up

Divisione1

Divisione3

Servizio2

Risultatiparziali

Risultato per

l’utente

Risultatiparziali

Risultatiparziali

Processo assistenziale (il percorsopercorso del cittadino all’interno dell’Azienda)

Territory

IN GOD WE TRUST.

ALL OTHERSMUST USE DATA.

W.E. Deming

WHERE, WHAT, WHEN, HOW… TO EVALUATE?

INDICATORSINDICATORS

• opening of opening of

educational educational

clinics managed by clinics managed by

nursesnurses

• number of patients number of patients

following the pathfollowing the path

• use of toolsuse of tools

• home access by home access by

cardiologistcardiologist

PROCESSPROCESS RESULTRESULT

• reduction in reduction in

hospitalisationhospitalisation

• increase in the increase in the

amount amount of of

Integrated Home Integrated Home

CareCare

• illness historiesillness histories

Accountability