Building a model of integrated care (ic) in home care (hc)

摘要

Introduction : Catalonia has a singular intensive process of aging reaching more than 1/3 of population and more than 12% population over 65 and 80 years old respectively by the half of this century. Some of the responses from a policy prespective will be to consolidate our Chronic and Integrate Health and Social Care strategy to deal with this challenge Description of policy context and objective : Approximately 5% people over 65 years old are covered by home health care or home help services (10% in case of telecare) which are organised separately by Department of Health, Department of Welfare and municipalities. As Department of Health has built an agregated data base of morbidity provided by Primary Health care, hospital care, long-term care and mental health we know almost 60% of people included in HC have complex needs and 12% with advanced chronic conditions. 96% of population included in home care are related to 20% of general population with high burden of multimorbidity and complexity. Additionally it has performed an analysis from data of Departament of Welfare related to home care provided by social services. Additionally they are using over 4, 3, 3,5 and 3 times more Primary Care services, A&E, pharmacy and day care facilities respetively compared to general piopulation and they are using 6 and 23 times more emergency admissions and long term care facilities Objective : A new model of Integrated home care and home help want is being developed in a population base to offer a proactive management and care for people covered in this new IC program at home achieving better health and wellbeing outcomes, better service utilization and experience of care of person and carer Targeted population : People with complex health and social care needs living at home / disability / frail requiring care at home Highlights (innovation, Impact and outcomes) :It has been priorised the following actions: -Creation of a model of governance between health and social care authorities in a population base approach -Each territory should elaborate functional plan related to home care -Introduction of joint assessment and planning -Design an 24/7 model covering rapid response for crisis situation -Better coordination between home care services and telecare -Smoother Transitions from hospital to community -Extension of home aides/appliances and Occupational Therapy (OT) -Better joint management of carers from both health and social perspective -Update of "community services map" accessible from health and social care services -Information Communication Technologies supporting integrated care in home care -Joint evaluation framework -Identification and share of best practice in IC in Home Care Comments on transferability : After review of evidence and good practice in grey literature there are few examples of porgress in Integrated Care in Home Care especially for care of people requiring joint assessment and care planning from both health and social care sector belonging to different sectors There are barriers to integration and challenges in the area of shared Information Systems, pooling budgets for specific popultaions who require joint health and care approach.