Abstract
Due to the ageing population and the increase of chronic diseases, new models of health care delivery are unavoidable.
Ribera Salud(RS), through design thinking methodology and with the participation of citizens and professionals, has developed an innovative Population Health Management program where technology is one essential pillar:
Risk prediction: A population stratification model based on the John Hopkings tool, ACG to predict the level of risk of every citizen.
Creation and monitoring of personalized care plans, including prevention and health promotion. An assessment is done to every citizen and a personalized care plan is created. This process is supported by “TruCare” (PHM tool).
The empowerment of the patients to self-manage their pathology by providing a variety of technologies (RS health portal, “YoSalud”, to communicate directly with the doctor, to share health information, etc).
Data analysis: Measurements of outcomes through an in-house developed Business Intelligence tool: Core - Insight.
The main aim of this program is to improve clinical and financial outcomes.
The whole population within the health departments managed by RS in the Valencian Community (310.000 citizens) is the targeted population.
Citizens and professionals are the stakeholders of the program and their implication from the beginning has been critical.
In 2010 RS developed Yosalud. In 2012 the company launched a Chronic Plan focused on high risk level patients. Since then, continual improvements have been developed, and, in November 2016 we implemented “TruCare”, with the aim of covering the whole population, and we also improved our BI tools and YoSalud.
Highlights:
Reduction in hospital admissions and emergency visits
Better coordination among professionals
Better accessibility for patients (direct contact through YoSalud)
Improvement in the citizens` satisfaction
Awareness of the importance of a healthy lifestyle through personalized information in YoSalud.
PHM is a critical tactic for developing sustainable healthcare models as, through it, health organizations can improve the health status of their population by providing each person the care needed in a proactive manner, and technology is the key to achieve this objective.
This program can be transferred to any organization, mostly to those with integrated care between primary care and hospitals. It can also be transferred to those that just manage primary care but which have a good coordination with other levels of care.
Conclusions: PHM is an effective model to improve population health. Engagement of patients and health professionals is essential in this model. Technology provides the basis to make things different, easier, more accessible and effective.
Although PHM was identified many years ago as a critical tactic for developing sustainable healthcare models, very few healthcare organizations have successfully implemented effective programs. Barriers must be overcome.
Lessons learned: Community participation: it’s critical that citizens and professionals participate in the design and implementation of the program. Design Thinking can be a good approach.
Use of technology to improve communication, coordination and efficiency.
Empowerment of the patient from the beginning, actively participating in the program.
Providing continual feedback to professionals.
Never forget the humanism of the relationship between patients, doctors and nurses.
Reference:
Available from https://www.youtube.com/watch?v=vGnZiCgkdo4