What is it?
- A technological model for the development, personalization, implementation and critic assessment that allows to confront the challenges of Management Programs for the Care of Chronic Patients.
- That provides innovative solutions to the Chronic Programs Management with an integrated vision of the socio-sanitary services, with an implementation progressive and very flexible, according to each customer priorities.
- That help patients to “better meet” (adherence) the instructions of the socio-sanitary professionals that work around him/her.
- That facilitates the proactive and preventive actuation of the professionals and empowers the role of the Case Manager.
- That generates more sustainable models where the savings can be measured.
- That improves Patient perception of the Quality levels of the services received.
- Because the new exigencies of current demographic trends
– Demography: Ageing.
– Multi- Morbidity-) Chronicity growing à prevalence of long-term conditions = greater consumption of socio-sanitary resources.
– Dependency growing (SOCIAL dimension associated with ageing).
– Informal Net: change in family models (SOCIAL variable).
- Because the need of New Care Models: crisis and sustainability of the current socio-sanitary model
– There is to segment / stratify / classify populations (Kaiser, CARS, Barthel…) to better serve the patient.
– There is to balance / optimize resources: and its use to the different population segments: Prevention → Self-Management → Disease Management → Case Management.
- The new needs of the socio-sanitary model present New Challenges
– Evolution towards Care Continuity → requires an effective Socio-Sanitary Coordination.
– The patient in the centre of the model: actively participating, motivated, committed, “adhered”.
– Multidisciplinary Network around the Patient: professionals (primary care, nursery, specialists) + informal environment (caregiver, familiar, social worker).
– Assistive Routes adapted to the Patient: care process based on Individualized Care Plans which homogenize care, reduce the dispersion of individual professional judgment and spread the workload.
– Obligation to Optimize Resources: empower the model that allows the chronic patient stay at home (in the community), reduce hyper-attendance, distribution of workload among multidisciplinary network of professionals…
- Development of a Preventive / Proactive social health model versus the traditional Reactive model
– It is 90% an Organizational Change: Chronic Plan, Action Protocols, Chronics, homogeneous Assistive Processes, Professional will, Overload Management (Primary) vs. Underutilization (Nursing).
– Requires tools for the CONTROL of the model implementation: that allows the management of multiple roles with different tasks/responsibilities as well as the management of highly diverse and distributed populations.