RESUMO
BACKGROUND: Telehealth (TH) was introduced as a promising tool to support integrated care for the management of chronic obstructive pulmonary disease (COPD). It aims at improving self-management and providing remote support for continuous disease management. However, it is often not clear how TH-supported services fit into existing pathways for COPD management. The objective of this study is to uncover where TH can successfully contribute to providing care for COPD patients exemplified in a Greek care pathway. The secondary objective is to identify what conditions need to be considered for successful implementation of TH services. METHODS: Building on a single case study, we used a two-phase approach to identify areas in a Greek COPD care pathway where care services that are recommended in clinical guidelines are currently not implemented (challenges) and areas that are not explicitly recommended in the guidelines but that would benefit from TH services (opportunities). In phase I, we used the care delivery value chain framework to identify the divergence between the clinical guidelines and the actual practice captured by a survey with COPD healthcare professionals. In phase II, we conducted in-depth interviews with the same healthcare professionals based on the discovered divergences. The responses were analyzed with respect to identified opportunities for TH and care pathway challenges. RESULTS: Our results reveal insights in two areas. First, several areas with challenges were identified: patient education, self-management, medication adherence, physical activity, and comorbidity management. TH opportunities were perceived as offering better bi-directional communication and a tool for reassuring patients. Second, considering the identified challenges and opportunities together with other case context details a set of conditions was extracted that should be fulfilled to implement TH successfully. CONCLUSIONS: The results of this case study provide detailed insights into a care pathway for COPD in Greece. Addressing the identified challenges and opportunities in this pathway is crucial for adopting and implementing service innovations. Therefore, this study contributes to a better understanding of requirements for the successful implementation of integrated TH services in the field of COPD management. Consequently, it may encourage healthcare professionals to implement TH-supported services as part of routine COPD management.
Assuntos
Prestação Integrada de Cuidados de Saúde/métodos , Pessoal de Saúde/psicologia , Doença Pulmonar Obstrutiva Crônica/terapia , Telemedicina/organização & administração , Grécia , Humanos , Entrevistas como Assunto , Equipe de Assistência ao Paciente , Pesquisa Qualitativa , AutogestãoRESUMO
BACKGROUND: Comprehensive assessment of integrated care deployment constitutes a major challenge to ensure quality, sustainability and transferability of both healthcare policies and services in the transition toward a coordinated service delivery scenario. To this end, the manuscript articulates four different protocols aiming at assessing large-scale implementation of integrated care, which are being developed within the umbrella of the regional project Nextcare (2016-2019), undertaken to foster innovation in technologically-supported services for chronic multimorbid patients in Catalonia (ES) (7.5 M inhabitants). Whereas one of the assessment protocols is designed to evaluate population-based deployment of care coordination at regional level during the period 2011-2017, the other three are service-based protocols addressing: i) Home hospitalization; ii) Prehabilitation for major surgery; and, iii) Community-based interventions for frail elderly chronic patients. All three services have demonstrated efficacy and potential for health value generation. They reflect different implementation maturity levels. While full coverage of the entire urban health district of Barcelona-Esquerra (520 k inhabitants) is the main aim of home hospitalization, demonstration of sustainability at Hospital Clinic of Barcelona constitutes the core goal of the prehabilitation service. Likewise, full coverage of integrated care services addressed to frail chronic patients is aimed at the city of Badalona (216 k inhabitants). METHODS: The population-based analysis, as well as the three service-based protocols, follow observational and experimental study designs using a non-randomized intervention group (integrated care) compared with a control group (usual care) with a propensity score matching method. Evaluation of cost-effectiveness of the interventions using a Quadruple aim approach is a central outcome in all protocols. Moreover, multi-criteria decision analysis is explored as an innovative method for health delivery assessment. The following additional dimensions will also be addressed: i) Determinants of sustainability and scalability of the services; ii) Assessment of the technological support; iii) Enhanced health risk assessment; and, iv) Factors modulating service transferability. DISCUSSION: The current study offers a unique opportunity to undertake a comprehensive assessment of integrated care fostering deployment of services at regional level. The study outcomes will contribute refining service workflows, improving health risk assessment and generating recommendations for service selection. TRIALS REGISTRATION: NCT03130283 (date released 04/06/2018), NCT03768050 (date released 12/05/2018), NCT03767387 (date released 12/05/2018).
Assuntos
Análise Custo-Benefício/normas , Prestação Integrada de Cuidados de Saúde/normas , Idoso , Protocolos Clínicos , Prestação Integrada de Cuidados de Saúde/economia , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Estudos Observacionais como Assunto , Avaliação de Resultados em Cuidados de Saúde , EspanhaRESUMO
Current healthcare systems are struggling with rising costs and unbalanced quality of care. Integrated care (IC) is a worldwide trend in healthcare reforms designed to tackle these problems. ACT@Scale is a partnership of leading European regions, industry and academia which aims to identify, transfer and scale-up existing integrated healthcare practices. In this context, participating programs are applying iterative process improvement cycles using collaborative methodologies. The vision of learning health systems (LHS) is similar to IC, but it focuses on IT means as a change enabler for rapid and continuous knowledge integration into better outcomes. In this paper, we present the ACT@Scale program as an example of an LHS that monitors integrated care performance and effects of process improvement cycles.
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Atenção à Saúde , Reforma dos Serviços de Saúde , Humanos , AprendizagemRESUMO
OBJECTIVES: Population-based health risk assessment and stratification are considered highly relevant for large-scale implementation of integrated care by facilitating services design and case identification. The principal objective of the study was to analyse five health-risk assessment strategies and health indicators used in the five regions participating in the Advancing Care Coordination and Telehealth Deployment (ACT) programme (http://www.act-programme.eu). The second purpose was to elaborate on strategies toward enhanced health risk predictive modelling in the clinical scenario. SETTINGS: The five ACT regions: Scotland (UK), Basque Country (ES), Catalonia (ES), Lombardy (I) and Groningen (NL). PARTICIPANTS: Responsible teams for regional data management in the five ACT regions. PRIMARY AND SECONDARY OUTCOME MEASURES: We characterised and compared risk assessment strategies among ACT regions by analysing operational health risk predictive modelling tools for population-based stratification, as well as available health indicators at regional level. The analysis of the risk assessment tool deployed in Catalonia in 2015 (GMAs, Adjusted Morbidity Groups) was used as a basis to propose how population-based analytics could contribute to clinical risk prediction. RESULTS: There was consensus on the need for a population health approach to generate health risk predictive modelling. However, this strategy was fully in place only in two ACT regions: Basque Country and Catalonia. We found marked differences among regions in health risk predictive modelling tools and health indicators, and identified key factors constraining their comparability. The research proposes means to overcome current limitations and the use of population-based health risk prediction for enhanced clinical risk assessment. CONCLUSIONS: The results indicate the need for further efforts to improve both comparability and flexibility of current population-based health risk predictive modelling approaches. Applicability and impact of the proposals for enhanced clinical risk assessment require prospective evaluation.