Indicators for monitoring and evaluating territorial outcomes of Integrated Care in Older People with Complex Needs

Background: Within the framework of the Transformative Project (TP) on Integrated Care, funded by the Catalan Health System and implemented across five territories (Osona, Alt Maresme, Selva Marítima, Alt Empordà, and Baix Empordà), we present the results identifying indicators that may be useful for monitoring and evaluating territorial outcomes in integrated care for older adults and complex needs.

To operationalize the care for this population group, the Catalan Department of Health defined two patient profiles: (I) Patients with Chronic conditions and Complex care needs (PCC) and (II) patients with advanced chronic disease and limited life expectancy (MACA).

Consistent with previous literature, the TP selected indicators that capture person-centred care coordination, coordination across levels and care services, and the response to health crises (planned low-intensity and unplanned high-intensity resource use).

The aim of this study is to automatically obtain, through information systems, a set of selected clinical indicators for monitoring and evaluating integrated care outcomes among people aged ≥80 years, identified as PCC or MACA.

 

Approach: A retrospective, descriptive observational study was conducted using an administrative database that compiles aggregated data from the last 12 months from various information systems of the Catalan Health Service. The study population included people aged ≥80 years, identified as PCC or MACA, assigned to one of the 31 Primary Care Center across five territories of Catalonia (Alt Maresme, Alt Empordà, Baix Empordà, Osona, and Selva Marítima).

Indicators related to the following are studied:

- Care model: % identification of PCC or MACA; % of Shared Individual Intervention Plan (SIIP) correctly completed as of December 2024.

- Use of healthcare resources: number of Primary Care (PC) contacts (in-person and by telephone); rate of Emergency Department visits (ED); rate of Acute Hospital (AH) admissions; rate of Intermediate Care (IC) admissions during 2024.

- General indicators: mortality rate, polypharmacy (≥10 chronic medications), and days spend at home in 2024.

 

Results: The population aged ≥80 years across the five territories comprised 36,810 individuals, of whom 11,510 (31.27%) were identified as PCC, 1,302 (3.54%) as MACA, and 23,998 (65.19%) as non-identified. Among these: SIIP coverage: 74.91% (PCC) and 71.20% (MACA). Mean PC contacts: 19 (PCC) and 25.1 (MACA). ED visits per 1,000 inhabitants: 945.15 (PCC) and 1,248.25 (MACA). AH admissions per 1,000 inhabitants: 536 (PCC) and 842 (MACA). IC admissions per 1,000 inhabitants: 159 (PCC) and 519 (MACA). Mortality per 1,000 inhabitants: 156 (PCC) and 562 (MACA). Polypharmacy: 4,650 (38.18%) PCC and 503 (34.24%) MACA. Mean days at home: 357 (PCC) and 342.5 (MACA).

 

Implications: The indicators show that population aged ≥80 years identified as PCC and MACA are high consumers of healthcare resources and exhibit high rates of polypharmacy.

These indicators should enable continuous evaluation of the outcomes of future interventions targeting this population group. In addition, we would like to study whether this set of selected indicators are scalable and can be implemented in other territories.