COPD

The aim of the integrated care programme “Home Hospitalisation and Early Discharge for COPD patients” is to provide an acute, home-based, short-term intervention that substitutes conventional hospitalisation in full (hospital avoidance) or partially (early discharge).

The specific objectives are:
1) to reduce the number of readmissions and/or need for emergency room care; and,
2) to shorten the length of overall stay.

Similarly, the aim of the integrated care programme “Prevention of Exacerbations in COPD patients” is to provide a low intensity follow-up that allows the early detection of a worsening of the respiratory condition and appropriate reaction to it.

The specific objectives are:
1) to reduce the number of exacerbations in COPD patients; and
2) decrease the use of institutional health care resources (Admissions, Emergency room, outpatient clinics, and primary care).

All Integrated Care programmes at Hospital Clínic share a common approach composed of five building blocks or phases. The blocks generally correspond to different events in a time axis. Each of these building blocks includes a well-defined set of tasks to be carried out. Also, most typically, each block involves a limited number of actors. Each of the following five blocks renders outcomes that are relevant for the execution of the next block or phase.

1) Case identification
This first block corresponds to the entry level for any programme. The main activity being done is the detection that a particular individual might meet the eligibility criteria to be treated under a specific integrated care programme.

2) Case evaluation
This second phase concerns the assessment of the patient by “integrated care” professionals. At Hospital Clínic this task is usually carried out by the integrated care case manager with/without the support of other members of the integrated care team. The case manager can be a nurse, a doctor or another professional. But other possibilities are also acceptable and sometimes more convenient.

3) Work plan definition
This phase concerns the planning of the activities to be carried out in the patient. Typically, a template of activities is available for different categories (severity) of patients. The case manager / integrated care team adapt this template to the specific needs of the patient.

4) Follow-up
This is the phase when the individual plan for the patient is executed. Unexpected events occurring during this phase are handled by the integrated care team.

5) Discharge
Discharge occurs when the patient does not longer meet the inclusion criteria for the specific programme he/she had been allocated. Discharge may mean moving the patient to another programme but it can also mean referral to institutional care (admitting the patient to the hospital, follow-up by primary care, etc.).

The construction of integrated care programmes developed in Hospital Clinic in Barcelona required the consideration of aspects of service redesign so that, for the selected group of patients, services could be presented in an integrated fashion. Traditionally, the treatment of these patients had always followed a reactive, fragmented pattern, with exacerbated COPD patients are admitted at the hospital and discharged to primary care without any transitional support

Important distinctive characteristics of the programmes are:
1) normalisation of work practices permitting a reduction of inter-professional variability;
2) redefinition of the roles of the professionals in the integrated care programmes; allowing reallocation of professional to activities of higher added value; and
3) optimisation of allocation of the resources available, thus enabling managers to better planning needed services in advance.

An alternative safe option to traditional care
Integrated care services are a safe alternative to be considered for COPD to other more institutional approaches. The same is valid for other medical and/or surgical conditions. In general, patients that benefit from more regular and less intensive follow-up are the candidates of choice for such programmes. However, also patients in need of more demanding care service are eligible such in the case of home hospitalisation. The studies carried out have shown better clinical outcomes, increased patients’ and professionals’ satisfaction and cost-containment.

Need for organisational changes
The type of collaboration and coordination across health care agencies that is implicit in the development of integrated care programmes usually requires of some organisational changes. In most of the cases, this is in line with the implementation of a territorial vision that creates an explicit context for the interactions between different providers (hospital, primary care centres) and community resources.

New professionals’ skills
Some of the specificities of integrated care programmes required the development of new skills in the professionals involved. Abilities such as the training the patients require methods that many professionals do not know well enough. Accordingly, continuous professional development initiatives are needed.

Importance of dedicated resources and logistics
In the case of Hospital Clinic, the creation of a dedicated integrated care unit had a major effect in ensuring a smooth coordination with other services at the hospital. It meant a point of reference from where all the required logistics to support the programmes could be arranged in an easier way.

Information and communication technologies
The use of information and communication technologies had an enabling effect in the development of the integrated care programme at the hospital. Albeit the difficulties found in the pace of the development and the fact that occasionally the technology was not working properly, all the actors recognised that it was needed to be able to move to work practices that required such level of coordination and collaboration. This should not be understood as a replacement of pre-existing proprietary Electronic Health Record.

Business case, reimbursement mechanisms
The sustainability of an integrated care programme is linked to the formulation of a business case that includes, if the existing ones are not satisfactory, the formulation of novel reimbursement policies. Because of the mix of potential actors involved in integrated care programmes, unusual models, such as share-risk agreements involving also industry or pharma suppliers, should be also considered.