New Model of Integrated Care for Patients with Immune-Mediated Inflammatory Diseases

Esther Chamorro-de-Vega; C. M. González; L. Menchén; O. Baniandrés; A. Herranz; C. Lobo-Rodríguez; R. Romero-Jiménez; A. Ais-Larisgoitia; E. Lobato-Matilla; A. López-Esteban; A. López-Calleja; I. Marín-Jiménez; I. Monteagudo; P. Morales de Los Ríos; J. C. Nieto; M. Ferris-Villanueva; M. J. Lizcano; M. P. Simón Moreno; M. Sanjurjo; S. García de Sanjosé

doi:10.5334/ijic.7741

Figures & Tables

Table 1

Challenges, barriers and proposed solutions to the new model of care.

CHALLENGE	BARRIER	SOLUTION
*Direction and Strategy*
Several clinical services involved without common governance.	Conflict of powers between heads of service.	Transversal leadership system. Semi-annual rotation of the leadership position.
Incorporate patients into decision making.	Absence of references in the institution.	Incorporation of patients into the governance team.
The best multidisciplinary model of care and preferential circuits is not defined.	Absence of references.	Creation of a committee of experts. Bibliographic review. Hiring a specialized consulting firm.
Unify the center in the same location.	Need to renew facilities. New location available away from the general hospital.	Search for financing for the works. Transfer between locations.
Ability to respond to expected patient demand.	High care volume workload. Call effect due to the center’s novelty.	Prioritize patients treated with biological therapies or targeted molecules.
*Processes Management*
Patient-centered clinical care.	System focused on the process.	Redefinition of processes. Preparation of a patient-centered process map.
Patients with more than one IMIDs not correctly integrated.	Complexity in the management of these patients by different professionals.	Creation of a multidisciplinary committee for the management of these patients.
Professional maintenance of each patient.	Center far from individual services.	Reconciliation of the agendas of the professionals involved.
Incorrect referral of patients.	Lack of knowledge by professionals.	Dissemination plan for the criteria for referral to the center.
Continuous evaluation of the results.	Difficulty of data exploitation.	Development of a specific dashboard. Collaboration with the hospital’s quality service.
*People*
Need for additional personnel to cover the service.	Lack of resources to hire new personnel.	Conciliation and displacement of previously available personnel.
*Alliances*
Improve communication with patient.	Lack of resources.	Search for financing to develop telemedicine projects.
Improving continuity of care between different levels.	Poor coordination with primary care.	Preparation of a training and communication plan between care levels.
National and international recognition as a reference center.	–	Seek support from hospital management and industry. Preparation of an image and dissemination plan.

Table 2

Main initiatives implemented.

Direction and Strategy

Definition of the CEIMI’s mission, vision, and values

Definition a transversal leadership system, in cooperation with all the hospital services involved: establishment a Steering Committee to improve communication and facilitate decision-making

Incorporation of the patient into the governance system. We use the satisfaction surveys to evaluate patient experienced.

Strategic planning deployed to annual operational plans, with short-term objectives and assignment of responsibilities

Implementation of a scorecard and annual SWOT analysis according to stakeholders’ needs and CEIMI performance

Creation a Case Committee to make a collegiate and shared decision about the most appropriate care plan for each patient

Creation a multidisciplinary consultation in which patients with different concomitant IMIDs pathologies were attended by different specialists simultaneously

Carrying out focus groups for humanization where the needs and expectations of patients, doctors, nurses and service personnel have been collected

Creation of the APN role with a key role in the coordination of care activity, in the planning, management of care and treatment

Implementation of a program for the individualization of pharmacotherapy (Precision Medicine) to monitoring drug and antibody levels and to evaluate polymorphisms with the potential to predict their response or toxicity

Implementation of a tele-assistance service for ensure continuous patient care

Processes Management

Design of an integrated and coordinated patient care circuit
Definition of the process map of the CEIMI, assignment of the person responsible for each process and supervision through the Process Control Card, with monitoring indicators

Establishment of operational management meetings order to improve internal management

Implementation of a custom scorecard with short- and long-term indicators covering patient, customer and people satisfaction, society, activity and health outcomes

Definition of a structured calendar for the evaluation of different health outcomes to all professionals

Incorporation of Patient Reported Outcomes (PRO) into clinical practice including quality of life, health status, symptoms present, adherence and satisfaction. These PRO are measured through rigorously developed and validated questionnaires

Design, use, and analysis customer surveys to optimize CEIMI processes.

People

Creation of a welcome plan for staff

Definition of an organizational manual, that contains the organizational and functional description of the same, as well as the definition of the competency profiles of each of the professionals

Design, use, and analysis of work climate surveys to evaluate staff motivation and satisfaction, including their participation in the leadership system, regularly and to compare data with those of other organizations

Implementation of individualized development plans and structured training plans for all staff

Alliances

Improvement in partnership management, with objectives, monitoring and improvement actions defined for each alliance

Implementation of surveys for partners

Design and implement a School of Patient to reinforcing the education of the patient and their families

Developed training videos for patients in collaboration with Madrid School of Public Health

Systematization of innovation management and implementation of information systems technologies in all phases of the drug use process: i. CPOE in all consultations. ii. Advanced CDS system to support pharmaceutical validation; iii. e-MAR in Day Hospital; iv. Barcode control for treatments administered at Day Hospital; v. Robotization of dispensing in the Outpatient Pharmacy; vi. Home follow-up of patients using an in-house development App; vii. Home delivery system to prevent the most vulnerable patients from traveling to the hospital.

Goals, stakeholders and portfolio of services of the CEIMI.

Table 3

Differences between the old and new care model.

TRADITIONAL CARE MODEL	NEW INTEGRATED CARE MODEL	IMPROVEMENT
*Direction and Strategy*
Absence of mutual leadership team. Address dependent on each Clinical Service.	Transversal leadership system	Collaborative government. Participation of all professionals involved in decision making.
Case Committee no available	Case Committee	Collegiate and shared decision about the most appropriate care plan for each patient
Leadership system without patients	Patients included in the leadership system	Promote responsibility and empowerment of patients
Facilities distributed in multiple locations	Center located in a single location	The whole care process was performed on the same day and in the same place to avoid unnecessary hospital visits
Patients with more than one IMIDs	Mutidisciplinary consultations	Patients with different concomitant IMIDs were attended simultaneously in the same room by two or more different specialists
Model without nurses or with non-specialized nurses	Incorporation the figure of the APN with a key role	APN provide personalized and comprehensive quality care to patients and their environment through a care model of shared decision, patient-centered and coordinated between the different levels of care and health professionals
*Processes Management*
Process-centered model	Patient-centered model	Improving quality of care and patient experience
Multiple clinical circuits not coordinated with each other	Integrated and coordinated patient care circuit	Optimization of healthcare resources and improving patient experience
Evaluation plan not defined and dependent on each service	Implementation an evaluation plan	Measure results and optimize objectives
No standardized measurement of results or evaluation of processes	Implementation of a custom scorecard covering all process	Facilitates analysis and peer comparison
Patient Reported Outcomes not available	Incorporated Patient Reported Outcomes into clinical practice	Improvement clinical care
*People*
The competencies of each professional are not adequately defined	Development an organizational manual with adequate definition of competencies	Optimization of personal resources and improving professionals satisfaction
Welcome plan for staff not available	Creation of a welcome plan for staff	Improved staff satisfaction
*Alliances*
E-health tools not available	Teleconsultation and app available	Communication and real-time monitoring of patients and provide additional data to support clinical decision-making, improve the quality of care, and contribute to the empowerment of patients
Poor coordination with others services and primary care	Creation of internal alliances with different services and primary care	Improved coordination between care services and levelsnand the continuity of health care
School of Patient not available	Implementation of a School of Patient	Improve the education of the patient and their families

Table 4

Key performance indicator.

CLASS	INDICATOR	PERIODICITY OF EVALUATION
*Activity*	Nº of attended patients	Quarterly
	Nº of patients treated with BT or TT	Quarterly
	Nº of new patients starting treatment at CEIMI	Quarterly
	Nº of physician’s consultations	Quarterly
	- Nº of telematic consultations	- Quarterly
	- % of unscheduled consultations	- Quarterly
	Nº of pharmacist consultations	Quarterly
	- Nº of telematic consultations	- Quarterly
	Nº of nurse consultations	Quarterly
	- Nº of telematic consultations	- Quarterly
	Nº of drug dispensations	Quarterly
	Nº of home delivery dispensations	Quarterly
	Nº of sessions in Day Hospital	Quarterly
	Nº of patients attended at Day Hospital	Quarterly
	% patients treated of the Health Area	Quarterly
*Health*	Age, mean (SD)	Annual
	% Male	Annual
	Effectiveness
	% of patients in remission*	Annual
	% of patients admitted to hospital	Annual
	Nº hospital admission/patient/year	Annual
	Average stay of admission/patient	Annual
	% of patients with emergency room visits	Annual
	Nº emergency room visits/patient/year	Annual
	Safety
	% of patients with treatment suspension due to toxicity	Quarterly
	Severe infusion reaction	Quarterly
	Nº of patients with severe extravasation problems	Quarterly
	Quality of live
	EUROQOL, median (IQR)	Annual
	HAD, median (IQR)	Annual
	WPAI**, %	Annual
	WPAI***, mean (SD)	Annual
	QOL-RA, median (IQR)	Annual
	AsQOL, median (IQR)	Annual
	PsAQOL, median (IQR)	Annual
	IBDQ, median (IQR)	Annual
	DLQUI, median (IQR)	Annual
	Efficiency
	% of patients with tapering of the treatment	Quarterly
	% of patients with intensification of treatment	Quarterly
	% of patients with biosimilar molecule****	Quarterly
	Average cost per patient/year	Quarterly
	% patients with lower cost counseling	Quarterly
	Quality
	% of patients with adherence > 90%	Annual
	% of patients with drug levels	Quarterly
	% of patients with antibodies anti-drug	Quarterly
*Satisfaction*	Patient
	Average score on outpatient satisfaction	Annual
	With physicians	Annual
	With pharmacist	Annual
	With APN	Annual
	Coordination between professionals	Annual
	Customer
	Average score on internal customer satisfaction	Biannual
	Average score on external customer satisfaction	Biannual
	Average score on student/resident satisfaction	Biannual
	People
	Average global score on the work climate survey	Biannual
	Score of Physicians/pharmacist/nurses	Biannual
	Score of other non-sanitary staff	Biannual
	Score in specific aspects	Biannual
*Society*	Nº of clinical trials	Annual
	Nº of research projects	Annual
	Nº of publications	Annual
	Annual impact factor of scientific publications	Annual
	Nº of courses	Annual
	Nº of conferences	Annual
	Nº of visits received by other organizations	Annual
	Nº of mentions in the media	Annual
	Nº of twitter followers	Annual
	Nº of audiovisual tools	Annual
	Nº of prizes awarded	Annual

New Model of Integrated Care for Patients with Immune-Mediated Inflammatory Diseases

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