To improve Quality of Life of chronic patients, Manises Hospital and Quart de Poblet Local Council connect digitally through IDI EIKON technology.
The digital tool developed by IDI EIKON (AdsuM+), is being validated within the European project INCA. The solution allows to design specific Care Plans for people with Heart Failure and degenerative dementias. It is a pilot experience involving only those residents of city of Quart who consent to participate and respecting always privacy and data protection.
Social Department of Quart de Poblet Local Council and Manises Hospital, through Quart Primary Care Centre, have already begun to deliver a coordinated care using the software platform designed by the Valencian technology company IDI Eikon for chronic patients, in this case responding to two profiles: people affected by heart failure and people over 65 years with symptoms or diagnosis of degenerative dementia, Alzheimer’s type.
It is one of the five pilot experiences (pioneer in Spain) developed within the European project INCA, aspiring to significantly improve the daily reality of people involved in it. So has been explained this morning at a press conference by the mayoress of Quart de Poblet, Carmen Martinez and the Director of Primary Care Hospital, Carlos Rodrigo. The mayoress has stressed that care coordination is an imperative of modern societies; It is key to a humanized and quality care, and respect for health and social rights of any citizen. Whoever suffers from a disease imposing limits, while also lacking emotional, economic and social support … needs an integral answer responding to all their needs. An answer that any person is entitled to, without exclusion, to ensure access to all public resources and a dignified life.
The INCA project (Inclusive Introduction of Integrated Care) began to take shape in early 2014 with the involvement of the Valencian technology company IDI Eikon, who already had experience in this field in the United States; the City of Quart de Poblet, sensitized in the field of care coordination and already a partner of IDI Eikon in previous European projects, and the Department of Manises Health, working proactively with chronic patients for a while with a strategy defined and extended. The three parties agreed to apply to the by then opened European call dealing with this subject and together with other Member States formed the INCA Consortium. With the approval of the proposal by the European Commission, a hard work started to optimize the digital tool and put to run the coordination and communication mechanisms.
Quart de Poblet became one of the five INCA pilot experiences, since in addition to the two Spanish participating pilots (Manises-Quart and Murcia), there are the pilots from Latvia, Croatia and Cyprus. Finally, a year and a half later, end-users (patients) are included in the Municipality platform to take part of the coordination of care (initially pilots have been running from month 12, at a more professional level -clinicians and technical people- working for patients -but without their direct intervention, especially because of their advanced disease). It is recognised that proximity is the ultimate premise of care coordination, so those working this pilot project are the Primary Care Centre with the supervision of the Manises Hospital and the Social Services Department of Quart Municipality. To start implementation, it was necessary to initially limit the population. Municipality Social Services chose people over 65 years with symptoms or diagnosis of degenerative dementia, Alzheimer’s type, being the users that over time require more intensive care by social services while all of them are also being served by the health system.
In the case of Manises Hospital, the patients profile chosen was those suffering from heart failure. The reasons: “this is a condition with a high mortality rate, patients have poor quality of life and if proper care is not applied, hospital admissions are recurrent. However, it is one of the diseases that may benefit most of a proactive case management”, said Dr. Carlos Rodrigo. Between 3 and 5% of the population in the health area of Manises presents a serious chronic disease. Of these, about 3,000 patients have heart failure, 350 of them already in an advanced state.
The main problems of these patients are characterized by their continuous destabilization -difficulty breathing- with any effort that forces them to be regular visitors of emergency rooms. The INCA project provides a platform that allows to create a shared space by different systems: AdsuM+, which is the case manager for patients used by Manises Hospital (in the case of the Hospital) and Governalia, the tool used by the Department of Social Services of Quart de Poblet Local Council. In this common space, professionals from the two systems are able to interchange information quickly and permanently, designing, in each case, an Individualized Care Plan. The aim is to put the person in the centre of a care network conformed by all the people contributing in its chain of care: nurses, family doctors, specialists, social workers, caregivers…), all of which can result in a better integral care with higher quality.
The information is only shared if there is an express authorization of the person. “Even then, not all clinical and social information of the individual is shared, but only relevant information tha Social and Health Services should pay attention, such as the Agenda of Health Care, Social Benefits received or requested, the Alerts for changes in the patient situation (change of address, hospital admissions, etc.)”, explained Dr. Rodrigo.
Social Services responsible consider to be also very useful to ensure that any chronic patient included in the project be informed of their right to Social Benefits and apply to them, to know whether a person has dealt with health benefits that would be appropriate in its case (i.e. using a wheelchair), streamline procedures and avoid to travel when processing dependence request, reporting the need for a clinical assessment to facilitate early diagnosis, notify the Health Centre and warn that one of the “shared” users will be a few days away, etc. etc. to better adapt social and health interventions… Casuistry is extensive, “said Carmen Martinez.
