EIP AHA Valencia 2016 Towards an Active and Healthy Ageing. Emilia-Romagna Region - Reference Site EIP-AHA

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1 EIP AHA Valencia 2016 Towards an Active and Healthy Ageing Emilia-Romagna Region - Reference Site EIP-AHA A Regional Model to Predict Identify and Manage Multimorbidity and Frailty Mirca Barbolini Valencia 21 June 2016

2 The Region in a nutshell Agenzia Sanitaria e Sociale Regionale Resident Population 4.5 Million Local Health Trusts: 8 Research Hospitals: 4 University-Hospital Trusts & Hospital Trust: 4+1= 5

3 A Regional Predictive Model Applied to the whole adult population of the Region, to assess the risk of hospitalization: people 18 y.o. ( ) Utilize the regional health/administrative data Calculate the Risk Score (10 - very high risk; 1 - low risk). High level of statistic accuracy (C= 0.85)

4 Clinical-Administrative Databases Clinical Databases Unique patient identifier Demographics Patient Registry GPs Social Care -Care allowances for elderly and disabled -Residential Long-term care -Care for severely disabled -Social service Health Care Hospital care Home care service Mental Health Care Pharmaceutical Prescriptions Outpatient specialist care Intermediate care Hospice Emergency services Death registry

5 Information Collected Chronic Diseases/Multimorbidity Pharmaceuticals Specialist visits Hospitalization Home care Emergency care Adherence to Guidelines Quality of care indicators RISK SCORE

6 Profiles of Risk

7 Regional Profile of Risk - Other Tools Hospitalization Risk Profile Pathology Registers Cardiovascular Risk

8 The Regional Profile of Risk Case/Disease Management 2,7 % 3,3% 10% Very high Risk ( 25%) High Risk (15-24%) Moderate Risk (6-14%) Self Management 84% Primary Prevention Low Risk(< 6%) Population 18 y.o. - N= 3,765,891

9 Regional State of the Art 80 Community Health Centers Risk Profiles provided to GPs Activation of Professional Teams GPs, Specialists, Nurses, Physioterapists, Social Workers: a Proactive response Interdisciplinary Paths Clinical, Appropriateness and Adherence, Health Education Participation Patients, Caregivers, Associations

10 80 Community Health Centers (Casa della Salute) 10

11 10 Nurse Managed Community Hospitals 228 beds 11

12 Community Hospital unique model nurse managed limited number of beds than 30) clinical responsibility with GPs or Local Health Unit physician involvement of physiotherapists and careworkers Type of care nursing care rehabilitation (physical, respiratory and cognitive) promotion of patient empowerment and self-management care giver training 12

13 Integrated Models of Care Multidisciplinary, Integrated, and Participated Pathways of Care Ambulatory (Nurse-Based) Care for Chronic Diseases All in One Community Hospitals Integrated Home-Based Care

14 Transferability Population Identification Stratification of the Population Risk Profile Proactive Care Disease/Case Management Administrative - Health Information Systems Community Based Organizational Structures

15 For Further Information Case della Salute ( Antonio Brambilla

16 The Emilia-Romagna Commitments 2016 A1 Novel approach for improvement adherence to medical plans, medication and management of Bioresources and Pharma A3 Sunfrail B3 Delivering Integrated Care Models Best Practices SOLE / FSE Project PROFITER Project ARIA Project 16

17 ER - Reference Site Governance

18 SUNFRAIL Reference Sites Network for Prevention and Care of Frailty and Chronic Conditions in Community Dwelling Persons of EU Countries

19 SUNFRAIL Project Promoted by a network of Italian Reference Sites of the European Innovation Partnership on Active and Healthy Ageing (EIP-AHA) 3 rd EU Health Programme - WP 2014 To share experiences, good practices and tools to identify and manage frailty and multimorbidity EIP-AHA Initiative (A1, A3, B3) Italian Ministry of Health - Mattone Internazionale

20 PARTNER ORGANISATION ACRONYM LP1 The Partnership Regione Emilia-Romagna - Agenzia Sanitaria E Sociale Regionale, Italy (RER-ASSR) Aster - Societa Consortile Per Azioni, Italy (ASTER) PP2 Regione Piemonte, Italy (RHAP) PP3 Regione Liguria, Italy (LIGURIA) PP4 Azienda Ospedaliera Universitaria Federico Il Campania, Italy PP5 Centre Hospitalier Universitaire De Toulouse, France (GERONTOPOLE) PP6 Centre Hospitalier Universitaire Montpellier, France (CHRU) PP7 Universytet Medyczny W Lodzi, Poland (LODZ) PP8 Universidad De La Iglesia De Deusto, Spain (DEUSTO) PP9 PP10 Regional Health & Social Care Board Of Northern Ireland, United Kingdom European Regional And Local Health Authorities Asbl, Belgium (HSCB) (EUREGHA)

21 Synergies with the Ongoing EIP-AHA Initiatives Source: European Commission. Excellent Innovation for Ageing - a European guide: the Reference sites of the European Innovation Partnership on Active and Healthy Ageing EIP-AHA Reference Sites City of Oulu FI Ireland (COLLAGE) IE Merseyside Northern Ireland S.W. Scotland UK Wales Yorkshire and the Humber Gelderland and Overijssel Noord-Brabant Northern Netherlands Zuid-Holland Twente Region NL Sothern Danemark Region Skåne SE DK Saxon State DE CZ Czech Republic Uni Hospital Olomuc Centro PT (Uni Coimbra) Andalucia Catalunya Galicia Región de Madrid País Vasco Valencia-La Fe E Alsace Languedoc-Roussillon Paris Pays de la Loire F IT Liguria Campania Emilia-Romagna Friuli Venezia Giulia Piemonte

22 SUNFRAIL General Objectives To improve the identification, prevention and management of frailty and care of multimorbidity in community dwelling persons (over 65) of EU countries. Specific Objectives 1. To design an innovative, integrated model for the prevention and management of frailty and care of multimorbidity (outcomes of the EIP-AHA). 2. To validate the model: assess existing systems and services targeting frailty and multimorbidity citizen s/patient s needs. 3. To assess the potential for the adoption/replication and sustainability of the model (good practices) in different organizational contexts. 4. To promote the dissemination of the results (decision makers - regional, national, EU level).

23 Reference Sites Systems Reflecting Frailty Region Reference Site Frailty Dimensions Chronic conditions Multi morbidity Adherence therapy Falls Prevention Social Economical #1 #2 #3 #4 #.. Activities/Best practices

24 Frailty: Areas Challenging Health Care Services Primary prevention/early Detection Diagnosis a) Screening the population for frailty using both quantitative or qualitative approaches a) Identification and evaluation of frail and pre-frail patients Secondary prevention/care a) Management of frailty progression Emergency/Hospitalization a) Management of hospitalized frail patients Building Capacity/ professionals/social network a) Improving "Patient Centered Care"

25 Frailty Ecosystem for each Reference Site Different Possible Models Patient Diagnosis Prevention [ ] Economical Treatment guidelines Social Management in-hospital Management out-hospital Educational

26 Main Outcomes Operational Definition of Frailty and Pre-Frailty Biomedical vs. Bio-Psychosocial Model Biomedical - Biological: Age, sex - Health-diseases - Life Styles: physical activity, nutrition... - Risk Factors: smoke, alchool.. - Family network Criteria of Inclusion? Psycosocial Well being (physical, psychological) Independent living Socialization Resources: health care, social interaction, sport, leisures Perceived/ Expressed Needs? Loss = Pre-Frailty?? Frailty or Pre-Frailty??

27 Main Outcomes A shared model-good practices on frailty and multimorbidity A tool kit for the prediction of frailty and multimorbidity: Primary care -Instruments to assess the risks of frailty: physical, cognitive, nutritional and psycosocial conditions (biomedical, individual, socio-economic dimensions) -to support the adoption of care pathways (early detection, management) Integrated care -methods and instruments to predict multimorbidity Other tools: -Instruments for professional s capacity building -Analysis of costs

28 REGIONE MARCHE PARTICIPATION OF ITALIAN REFERENCE SITES TO THE JOINT ACTION ON FRAILTY Main Objectives Engage in mutual learning on the identification, prevention and management of pre-frailty and frailty (physical, cognitive, nutritional, : socioeconomic, behavioral domains) (synergy with Sunfrail/other projects) Disseminate the outcomes of the JA and GPs emerging from Sunfrail project and related EIP-AHA initiatives involving Regions and relevant stakeholders of the EIP-AHA and beyond Participation of Italian Regions - Mattone Internazionale WP2 (Dissemination) (R. Marche-Leader) Other WPs

29 Regional Thematic Priorities for EU Projects i Population Ageing and Related Conditions: Frailty and Multimorbidity i Primary Health and Social Care - Multidisciplinary - Integrated Care i Early Detection, Prevention and Management of Chronic Diseases i Impact Assessment (Clinical - Economic) i Infectious Diseases: Information and Surveillance i Mental Health: Promotion and Prevention

30 Thank you for your attention! Mirca Barbolini romagna.it