0

Home Hospitalization and Early Discharge

(HH/ED) is a mainstream intervention at

Hospital Clinic that provides a home-

based individualized care plan,

administered as a hospital-based

outreach service, aiming at substituting

hospitalization and implementing

transitional care strategies for optimal

HH/ED discharge.

HH/ED is currently the first choice service

to be considered for most of the patients

admitted in the Emergency Department.

The current HH/ED is active on a 24x7

basis over the entire year with 36 beds

per day.

Nextcare Action 3 -

Home Hospitalization

and

Early Discharge

program at

Hospital Clínic de

Barcelona (HCB)

Authors: Nextcare Action 3 working group

Date: 22/04/2017

1

Table of contents

Purpose ....................................................................................................................................... 2

The setting ................................................................................................................................... 2

Service workflow .......................................................................................................................... 3

Service evaluation ........................................................................................................................ 8

Risk assessment/Stratification and service selection ..................................................................... 9

Annex I – Characterization of HH/ED patients ............................................................................. 13

Annex II – Adaptive case management (ACM) model and notation .............................................. 13

Annex III – Basic information for La Meva Salut (LMS) ................................................................. 14

2

Purpose

The current document analyzes the Home Hospitalization and Early Discharge (HH/ED) program at

Hospital Clinic de Barcelona (HCB) as a use case representative of Complex Chronic Patients (CCP)

management (Action 3 in the Nextcare project). The document has three main purposes: (i) describes

the basics of HH/ED, (ii) indicates key reports supporting ongoing strategies, and, (iii) proposes plans

in three core areas for action in Nextcare; these are:

• Service workflow definition and execution

• Service evaluation; and,

• Risk assessment/stratification and service selection

It identifies existing gaps and proposes specific developments to be achieved within Nextcare

lifetime. While acknowledging both conceptual and organizational differences between HH/ED and

transitional care (TC) strategies, the document also identifies the potential of HH/ED to contribute to

enhance shared care agreements between hospital-based specialized care and the community

through TC services1.

The setting

The HH/ED program of the Hospital Clínic of Barcelona (HCB) is a transversal unit under the Medical

and Nursing directions of the Institution. Its mission is to provide support for HH/ED to the different

Clinical Institutes/Services/Units and to facilitate the bridging between the hospital-based

specialized care and the community after hospital discharge.

Historical evolution

The HH/ED program was initiated early 2006 as a prolongation of a pilot experience showing

efficacy of the intervention through a randomized controlled trial (RCT) in chronic respiratory

patients2. A subsequent RCT showed the potential of TC to prevent early unplanned hospitalizations

in these patients3. Beyond these two initial studies

1,2, deployment of the HH/ED as a mainstream

service serving a broader spectrum of patients was initiated in 2006. Over the next ten years, the

different Clinical Institutes at HCB progressively joined the HH/ED program which has resulted in a

marked diversification of patients’ characteristics, as well as in a progressive increase in complexity,

1 Font D et al. Integrated Health Care Barcelona Esquerra (Ais-Be): A Global View of Organisational Development, Re-

Engineering of Processes and Improvement of the Information Systems. The Role of the Tertiary University Hospital in the

Transformation. Int J Integr Care. 2016;16(2):8 2 Hernandez C et al. Home hospitalisation of exacerbated COPD patients. Eur Respir J. 2003;21(1):58-67.

3 Casas A et al. Integrated care prevents hospitalisations for exacerbations in COPD patients. Eur Respir J. 2006;28(1):123-30

3

as described in detail in4. It is of note, that HH/ED has shown potential for healthcare value

generation both at provider and health system levels4. Moreover, the HH/ED has shown a huge

potential to contribute to the refinement of TC strategies after hospital discharge. Accordingly, the

document proposes implementation research methodologies5 aiming at identifying factors that

modulate effectiveness and sustainability of interventions associated to TC.

Profile of professionals

The HH/ED program is carried out by specialized hospital professionals. It is composed by three

physicians; Ten full-time Registered Nurses with Special Training (RNST), plus eight part-time RNST;

One full-time administrative, two part-time administrative officers with special training attending

the call center; One RN coordinator as well as one PhD, RN responsible of the Unit.

Extensive professional experience (> 10 years) in specialized units (i.e. Intensive Care Unit or

Emergency room) is usually required for RNST before moving to HH/ED. The physicians also have a

similar background in Internal Medicine, Emergency Department and/or Intensive Care. All of

professionals need at least 3 months of specific training in the HH/ED program.

Organizational issues

The program is open from Monday to Sunday, between 8.00 am and 09:00 pm. The period for

patients’ inclusion in the HH/ED program is from 09:00 am to 18:00 pm, from Monday to Sunday.

For incidences between 09:00 pm to 08:00 am, patients could either leave a voice message or

contact directly one of the specialists on duty through the call center. The initial average of 12 beds

per day has been increased to 36 beds per day in 2017 which represents approximately 1,500

admissions per year.

Service workflow

Patient eligibility and decision process for inclusion

Patient eligibility is assessed in the emergency room (HH), general ward (ED) or day hospital.

Potential candidates are identified by the attending physician in the respective units. He/She

4 Hernandez C et al. Implementation of Home Hospitalization and Early Discharge as an Integrated Care Service: a ten years

pragmatic assessment. PLoS One, 2017 (submitted) 5 Peters DH et al. Implementation research: what it is and how to do it. BMJ. 2013;347:f6753

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contacts with the HH/ED team that verify patient's eligibility for HH/ED using a standard protocol at

the time of enrollment. The time between the patient identification and patient assessment by the

HH/ED team do not exceed 2 hours.

Areas for improvement (to be included in the IPA – Innovació Processos Assistencials or

Innovation on Clinical Processes)

1. Development of Clinical Decision Support System (CDSS) supporting professionals for

identification of candidates for HH/ED. It will require definition of the patient profile

that may benefit from HH/ED, as well as the service (HH/ED) portfolio.

2. Enhance interactions between Hospital units and the CRM (call center) supporting

HH/ED. Currently, most of the interactions between professionals and the HH/ED team

are currently done by phone.

Assessment of the patient included into the program by the HH/ED team

The information required to characterize the case included in the HH/ED in order to define the

action plan during and beyond HH/ED is grouped into five dimensions, namely: (i) socio-

demographics, (ii) health team and system related factors; (iii) characteristics of patient’s chronic

conditions and primary diagnosis; (iv) risk factors and treatment; and, (v) patient dependence

factors. Information is obtained from the patient electronic health record and from standard

interview/questionnaire(s).

Areas for improvement (to be included into the IPA)

3. Development of Risk Assessment and Patient Stratification coupled with the service

portfolio.

The HH/ED program aims to develop and validate enhanced clinical predictive

modeling coupled with service portfolio selection with a two-fold aim:

o HH/ED:

� To identify additional home interventions during HH/ED

� To identify risk of failure during HH/ED (readmission and/or mortality)

and/or early readmission (30 day period) after HH/ED.

o Transitional care (TC):

� To attenuate risk of unplanned hospital-related events (emergency room

an hospital admissions)

� To optimize patient allocation in the best TC service.

Ultimately, Enhanced clinical prediction resulting from the novel modelling approaches will

feed clinical decision support systems (CDSS) displayed in the professional workstation.

See below – Section on Risk assessment and stratification

5

From hospital to home

Patients are transferred to home by ambulance on the same day of the evaluation after installing at

home the equipment needed during HH/ED period. The HH/ED program can provide home

equipment (oxygen, non-invasive mechanical ventilation, nebulizer, pump, monitoring devices, etc)

and offers the possibility to perform some tests at home (forced spirometry, etc.), intravenous

treatment (continue by pump or discontinue), measurements (blood or fluids testing), dressing and

drains. Pharmacological treatment at home is prescribed by the HH/ED physician and prepared by

the hospital pharmacy. The time elapsed between the end of the patient’s evaluation and his/her

arrival at home with all logistics ready for HH/ED do not exceed 4 hours.

Areas for improvement (template of tasks to be included into the IPA)

4. Current organization is highly efficient. But, it may benefit from enhanced data

tracking and management through inclusion of all procedures/options (structured

info on actors, companies, etc…) into the IPA in order to reduce phone/mails and

increase efficiency of communications).

Home intervention

At arrival to home, a telephone call to the patient is made by the RNST. The interventions are

planned following the international guidelines for each diagnostic group. The program is conducted

with a patient-oriented approach wherein management of co-morbid conditions and adherence to

therapy play central roles. The home visits include: i) assessment of patient clinical status; ii) control

of co-morbid conditions; iii) revision of the treatment plan including dressings and administration of

intravenous treatment if prescribed; iv) revision of biological tests, etc…; v) reinforcement of

therapeutic education and adherence; vi) checking of the equipment installed at the patient’s home;

and, vii) assessment of environmental conditions. All patients have already received basic

educational material. Remote patient self-monitoring (pulse oximeter, spirometer, scale and

glucometer) are potentially available to be incorporated in the individualized plan.

Discharge from HH/ED could be related to patient’s improvement, cure, hospital admission or death.

It is of note that integration & management of the patient action plan after HH/ED toward TC needs

improvement.

The proportions of specific home-based interventions during the HH/ED period since 2006 were: (i)

clinical visit & therapy (100%) ; (ii) intravenous therapies in 80%; (iii) peripheral blood sampling for

biological analysis in 94%, (iv) oxygen therapy, 31% of the cases and nebulizer therapy in 24%; (v)

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complex dressings and care in 23%; (vi) arterial respiratory blood gas measurements in 13%; (vii);

and; (vii) forced spirometry in 5% of the cases.

Areas for improvement during HH/ED (to be included in IPA)

5. Additional functionalities to be considered are e-consulting/communication services between

professionals and between patient/relative and professionals. Within this concept, we can

consider: video conference; remote pictures, etc…

6. Potential role for the personal health folder (La Meva Salut, LMS) as a tool to enhance

execution of patient action plan as well as to empower patient/relative for self-management.

It is of note that these two areas (5 and 6) may show special interest in specific TC services.

Enhanced coordination of professionals across healthcare tiers

Under this concept, we identify three different areas for action:

Firstly, between professionals from specialized units of the Hospital to support the HH/ED, if

needed.

Secondly, between the HH/ED team and different home-based service providers during HH/ED

(companies providing home-based equipment, Community Rehabilitation, etc)

Thirdly, between the HH/ED team and other community-based teams (primary care, palliative care,

ESICS, etc…). The aims are to facilitate HH/ED discharge and to activate the TC portfolio.

Areas for improvement (to be included in IPA)

7. Chat for e-consulting between professionals to support collaborative work

Again this ICT-Support service may have its optimal use within the scope of TC strategies

Adaptive case management (ACM) to support service workflow

Clinical processes, typically elucidated and modelled by physicians and nurses, define the patients’

action plans. The ultimate goal is to improve health outcomes through efficient use of resources

and clear responsibilities. However, flexibility in the execution of the patient action plan is required

7

by the fact that the clinical process execution may often show deviations from initial treatment

plan.

Adoption of adaptive case management (ACM) to support collaborative work constitutes a novel

approach that facilitates case managers to adapt well-structured service workflows to the

continuously evolving needs of the patients. This implies selection and scheduling of specific tasks

during case management and ad-hoc collaboration with other professionals across healthcare and

social support tiers, which facilitates collaborative decisions triggered by expected and unexpected

events. Conceptualization of the model is described in detail in6. Therefore, the HH/ED intervention

will be supported by a case management software platform (enhanced IPA in HCB) that will allow

the execution of well-structured but adaptable clinical workflows. To this end, the clinical workflow

of the HH/ED intervention is conceptualized in ANNEX II using the Case Management Model and

Notation standard (version 1.1). Moreover, ANNEX II displays a story board reflecting the added

value of adaptive case management (under construction).

The adaptive case management system will be open source and built-up on top of the current

health information systems (IPA for the HCB – to be linked with an equivalent clinical processes

engine in ECAP – the ICT system used in primary care) of the different healthcare providers and

using existing regional interoperability infrastructures (IS3: enhanced both HC3 & LMS).

In order to support both patient collaborative work and self-management, the personal health

folder already deployed in the region (LMS) is currently being adapted (see ANNEX III) for the

purposes of the program. The personal health folder (https://lamevasalut.gencat.cat) and certified

self-management mobile applications (https://appsalut.gencat.cat) will constitute a key ICT support

for the execution of the work plan, facilitating: (i) access to on-line educational material, (ii) data

collection (automatic & manual), and, (iii) interactions (mostly off-line) with health professionals.

Moreover, the personal health folder will contain information that can be pulled to the electronic

medical record (EMR) by the health professional.

Areas for improvement

8. Development of a new IPA supporting collaborative ACM for HH/ED (specific

proposals to be elaborated)

9. Development of a new IPA supporting collaborative ACM for TC (specific proposals

to be elaborated)

6 Cano I et al. An adaptive case management system to support integrated care services: Lessons learned from the NEXES

project. J Biomed Inform 2015;55:11–22. doi:10.1016/j.jbi.2015.02.011.

8

Service evaluation

Efficacy and effectiveness of the HH/ED program at HCB have been assessed in previous reports2.-4

.

The latter4 analyzes the state of the art of HH/ED in the Discussion section. Moreover, two other

publications3,7

illustrate on the high potential of TC strategies for health value generation within the

integrated care ecosystem of AISBE (Area Integral de Salut, Barcelona-Esquerra).

Nextcare is joining forces with the EU project SELFIE in order to refine the empirical evaluation of

cost-effectiveness of integrated care in AISBE by articulating two studies during the period 2017-

2018: (i) a population-based analysis of AISBE using registry data; and, (ii) a program-based study on

HH/ED combining registry data, electronic medical records (hospital and primary care) and

standardized patients’ questionnaires and interviews (see ANNEX I). We are using quasi-

experimental study designs with propensity score weighting in the statistical analysis using age, sex

and GMA (Adjusted Morbidity Grouper) scoring, as defined in the protocol of SELFIE’s empirical

study. The study outcomes will be structured following the Quadruple Aim Approach8,9,10

: (i) health

and well-being, (ii) experience with care, (iii) costs; and, (iv) professional engagement.

The main study goals will be fourfold: (i) demonstration of cost-effectiveness of the AISBE’s

approach; (ii) identification of factors that modulate success of large scale deployment of innovative

healthcare services, (iii) evaluation of key performance indicators useful for long-term follow-up of

innovative programs, and, (iv) collection of key information needed for refinement of transitional

care strategies aiming at minimizing hospital-related events; that is, avoidable admissions,

emergency-room consultations, early relapses and hospital-related mortality.

We aim to identify and validate key performance indicators (KPI) to be used for long-term follow-up

of large scale deployment of innovative services, namely: (i) highly selected program specific

indicators, (ii) maturity of implementation, and, (iii) impact of the intervention on the healthcare

system including cost analysis taking into account interactions between healthcare and social

support. The latter will be done following local guidelines generated by the PIAISS (program aiming

at fostering integration between healthcare and social support at regional level).

7 Hernandez C et al. Integrated care services: lessons learned from the deployment of the NEXES project. Int J Integr Care

2015;15: e006. 8 Stiefel M et al. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI

Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. (Available

on www.IHI.org) 9 Bodenheimer T et al. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam

Med. 2014 ;12(6):573-6 10

Baltaxe E et al. Study design of the empirical evaluation of the AISBE program in Catalonia. SELFIE

(http://www.selfie2020.eu/) (see protocol in Emdesk)

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A recently report submitted for publication11

describes the strategies for large scale deployment of

integrated care for complex chronic patients (CCP) in Catalonia. It is of note that the AISBE study is,

de facto, a subset of the overall study analysis described in the regional implementation plan.

Areas for action

10. The specific questionnaires and schedule for administration as well as the overall

study logistics will be completed by the end of May 2017.

Risk assessment/Stratification and service selection

The working plan is to develop and validate enhanced clinical predictive modeling for HH/ED with a

two-fold aim:

� During the HH/ED period:

o To attenuate risk of unplanned emergency room and hospital admissions

o To optimize patient intervention.

o To identify risk of failure (hospital admission and/or mortality) and/or early

readmission/mortality (30 days) after hospital discharge and mortality in order to

stratify patients and decide on the service portfolio to optimize care.

� Action plan after HH/ED discharge –

o To identify risk of late readmission/mortality (90 days) after HH/ED discharge; and,

o To stratify patients and decide on service portfolio for transitional care purposes.

Enhanced clinical prediction resulting from the novel modelling approaches will feed clinical decision

support systems (CDSS) displayed in the professional workstation. The high level strategy is to

develop enhanced clinical predictive modelling using a multilevel approach as defined in12

.

Areas for action

11. Developments and evaluation of the predictive modelling generated in the current

study will be carried out and implemented following a stepwise approach. For Phase I

(February-July 2017) the following milestones (M) are envisaged:

M1 - Submission of the study protocol to the CEIC – end of April 2017

M2 - Preparation for data extraction from electronic medical records (EMR) with Atomian

Medical Records13 – May 2017

11

Cano I et. al. Protocol for Regional Implementation of Community-based Collaborative Management of Complex Chronic

Patients. 2017. Accepted with minor revisions in npj Primary Care Respiratory Medicine 12

Dueñas I et al Proposals for enhanced health risk assessment and stratification in an integrated care scenario. BMJ Open,

May 2016. doi:10.1038/clpt.2013.24.52 13

Atomian Medical Records 2016. http://www.atomian.com/atomian-medical-records/

10

M3 - Initial model development using historical data 2006-2015 and multiple regression

analysis (May 2017)4

M4 - Extraction of EMR data (years 2010 – 2015) (May-June 2017)

M5 - Predictive model I (historical data). Evaluation with 2016 events (May 2017)

M6 - Predictive model II (historical data + GMA scoring) (June 2017)

M7 – Predictive model III (EMR data and EMR + GMA) (July 2017)

M8 - Report on implementation of patient similarity and case-based reasoning (CBR)

strategies (June 2017)

M9 - First CDSS prototype (July 2017)

M10 - Consolidation of risk assessment strategies for HH/ED & transitional care (July 2017)

M11 - Report (deliverable) & manuscript on risk assessment strategies (July 2017) including

formulation of subsequent phases of the study. The latter should include feeding

predictive modelling with raw data from other clinical sources (i.e., eCAP; HC3 within

the PADRIS14

umbrella) or from registries of the Catalan Health Surveillance System

(CHSS).

The two figures below summarize the predictive modeling approaches currently explored in

Nextcare for the HH/ED program and TC strategies:

14

Programa público de analítica de datos para la investigación y la innovación en salud (PADRIS) http://aquas.gencat.cat/es/projectes/analitica_dades/

11

Two core areas for action in May 2017 are the initial detailed formulation of the two service

portfolios for: (i) HH/ED and (ii) TC strategies, respectively. The initial formulation will be based on

current clinical knowledge and experience acquired in3. The first formal proposal for predictive

modeling and the correspondence with the service portfolio will be elaborated using historical data

of HH/ED obtained during the period 2006-2015. The following step will be enrichment of the

predictive modeling using GMA scoring as covariate. Thereafter, we will proceed to evaluation of

the modeling approaches using 2016 data obtained both from registries (Catalan Health

Surveillance System, CHSS) and electronic medical records. The deadline to accomplish the

milestones of Phase I is end-of-July 2017. The outcomes will be D2.3 (CONNECARE project) and a

manuscript for publication wherein the roadmap for Phase II of Nextcare Action I will be reported.

Areas for improvement – Elaboration of HH/ED service portfolio

12. Elaboration of an initial HH/ED portfolio based on clinical knowledge and previous

experience4 (May 2017) to explore matching between predictive modeling and

portfolio service selection (May to July 2017).

Preliminary logistic regression analysis of early readmission carried out in4 should be taken

into account for the developments of task 12.

12

Areas for improvement – Elaboration of proposals for Transitional Care service portfolio

13. Following the lessons learnt in7, we will elaborate a service portfolio covering TC

strategies (May to July 2017). It should encompass at least the following items:

a) Low–moderate patient complexity requiring standard community-based care in an

integrated care ecosystem

b) High complexity requiring program specific collaborative interventions across

healthcare tiers (i.e. HIV/AIDS; rare diseases (PAH, MS, etc..); respiratory therapies,

etc..)

c) High complexity due to multi-morbility & limited functionalities requiring specific

setting to prevent hospital-related events (explore ESICS experiences)

d) Candidates to Palliative care programs.

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Annex I – Characterization of HH/ED patients

Inclusion/exclusion criteria into HH/ED – Standard template (to be translated in English)

Characterization of HH/ED – Standard template (to be translated in English)

Annex II – Adaptive case management (ACM) model and notation

Story board illustrating on the added value of ACM (pending elaboration)

Case Management Model and Notation depiction of the workflow for the HH/ED intervention:

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Annex III – Basic information for La Meva Salut (LMS)

FITXA DE SERVEI DE Cat@Salut La Meva Salut

Entitat o empresa que sol·licita homologació: NEXTCARE

Plataforma: Sistema de gestió de casos adaptatiu per al programa d’hospitalització domiciliaria

SERVEI Home Hospitalization and Early Discharge (HH/ED) program

Descripció

Descripció del servei (English)

- Descripció funcional del servei (incloent manual d’usuari)

Patient eligibility and decision process for inclusion

Patient eligibility is assessed in the emergency room (HH) or in the general ward (ED).

Candidates are identified by the physicians of the respective units and posterior contact

with the HH/ED team (physician and case manager (RNST)), who verified the patient's

eligibility for HH/ED using a standard protocol at the time of enrollment. The time

between the patient identification and patient assessment by the HH/ED team do not

exceed 2 hours.

Assessment

The essential information is grouped into five dimensions, namely: i) socio-demographics

ii) health team and system related factors; iii) characteristics of patient’s chronic

conditions and Primary diagnosis; iv) risk factors and treatment and, v) patient

dependence factors (SF-36, Barthel Index). Additional information is obtained from the

patient electronic health records following the current legislation on access and

confidentiality of the clinical data. Assessment and follow-up are carried out using the ICT

platform described in detail in15.Thirty days after discharge, patients and caregivers are

administered a questionnaire on satisfaction with the HH/ED program via telephone.

From Hospital to Home

Patients are transferred to home by ambulance on the same day of the evaluation after

installing at home the equipment needed during HH/ED period. The program provides

home equipment (oxygen, non-invasive mechanical ventilation, nebulizer, pump,

glucometer, etc.) and offers the possibility to performing some tests at home (forced

spirometry, etc.), intravenous treatment (continue by pump or discontinue),

measurements (blood or fluids testing), dressing and drains. Pharmacological treatment

at home is prescribed by the HH/ED physician and prepared by the hospital pharmacy.

The time elapsed between the end of the patient’s evaluation and his/her arrival at home

with all logistics ready for HH/ED do not exceed 4 hours.

Home Intervention

At the time of arrival at home, a telephone call to the patient is made by the RNST. All

patients received basic therapeutic educational material. The interventions are planned

following the international guidelines for each diagnostic group. The program is

conducted with a patient-oriented approach wherein management of co-morbid

conditions and adherence to therapy have central roles. The home visits included: i)

assessment of patient clinical status; ii) control of co-morbid conditions; iii) revision of the

treatment plan including dressings and administration of intravenous treatment if

prescribed; iv) reinforcement of therapeutic education and adherence; v) checking of the

equipment installed at the patient’s home; and, vi) assessment of environmental

conditions. Remote patient self-monitoring (pulse oximeter, spirometer, scale and

glucometer) are available to incorporate in the individualized plan.

The specific home-based interventions during the HH/ED period are: (i) intravenous

therapies in 54%; ii) peripheral blood sampling for biological analysis in 53%, iii) transient

oxygen therapy, 39% of the cases and nebulizer therapy in 24%; (iv) complex dressings

and care in 21%; (v) arterial respiratory blood gas measurements in 13%; (vi); and; (vii)

forced spirometry in 10% of the cases. Discharge from HH/ED could be related to

improvement, cure, hospital admission or death.

Enhanced coordination of professionals across healthcare tiers

Hospital infrastructure: department ward, emergency room area and laboratories. One

physician of each specialized department provided support to the HH/ED team, if needed

Services providers:

a) During HH/ED: Companies providing respiratory equipment therapies, if

needed.

b) After HH/ED discharge: Primary care and palliative care team, the complex frail

patient program and the outpatient clinic from the hospital to ensure

15

transitional care. All services are coordinated by IC.

- Descripció del procés d’adhesió d’un ciutadà al servei com client/usuari

All acute or exacerbated chronic patients as well as surgical patients fulfilling criteria for

admission in the Hospital Clinic were considered as potential candidates for HH/ED.

Inclusion criteria for the study included those individuals: i) living in his/her house within

the healthcare sector; ii) having career during 24h per day; iii) having phone at home; and,

iv) signing written acceptance to participate in the study. Exclusion criteria for the study

were patients: i) living in a nursing home; ii) high risk of severe clinical deterioration not

treatable at home, as assessed by best medical judgment iii) admission in a short stay

unit; iv) severe psychiatric disorder, and, v) insufficient manpower of the professional team

running the program for additional admissions to HH/ED. All patients rejected at the

HH/ED services were admitted to the acute care hospital.

Període de prestació de servei

Between one and four weeks after hospital discharge.

Dades Tipologia i ubicació de les dades:

- Dades que s’utilitzen: Tipus de dades que s’utilitzen (administratives, assistencials,...)

Dades personals i professionals dels usuaris clínics del servei (nom, cognoms, posició, nom

d’usuari i contrasenya, idioma, adreça i telèfon de contacte, etc.), dades personals del

pacient (nom, cognoms, nom d’usuari, telèfon de contacte, e-mail i contrasenya, etc.) i del

cuidador (nom, cognoms, relació amb el pacient, e-mail, telèfon, etc.), dades clíniques dels

pacients (CIP, número d’història clínica, data de naixement, edat, sexe, gestor del pacient,

metge del pacient, descripció en text lliure del cas, etc.) i dades assistencials dels pacient

- Dades que genera el servei: Tipus de dades que genera (administratives,

assistencials,...). Dades d’adherència del pacient al servei (qüestionaris estàndard, dades

biomètriques, dades d’estil de vida (activitat física, sedentarisme, etc.))

- Les dades que es generen es guarden? Si

- Dades que es compartiran amb LMS o que transitaran entre LMS i el servei. Dades de

usuari i contrasenya del pacient per tal que LMS permeti fer single sign-on amb el servei.

- País on s’ubiquen les dades: País de la Unió Econòmica Europea

Actors - Usuaris o clients del servei: Pacients admeses al servei d’hospitalització domiciliaria del

Hospital Clínic.

- Proveïdors de serveis: Hospital Clínic

- Personal que intervé a la prestació del servei. En cas de professionals sanitaris explicar

com s’identifiquen i si deixen traça de les seves accions. Metge de medicina interna,

infermeres especialitzades i administratius del centre de trucades. El sistema

emmagatzema en un log totes les accions que es duen a terme per als diferents usuaris.

- Desenvolupadors de la plataforma: EURECAT

- Dipositari de les dades: Qui custodia les dades (incloure identificació i direcció)

EURECAT?

Relació entre actors - Descriure les relacions entre els diferents actors identificats.

Professional profile

The central HH/ED program is carried out by specialized hospital teams. It is composed by

one internal medicine physician, four full-time Registered Nurses with special training

(RNST), plus one part-time RNST, two part-time administrative officers with special

training attending the call center as well as a PhD, RN coordinator.

Seventy percent of RNST are RN plus Master and all of them have worked at least 15 years

at the hospital (Intensive Care Unit or Emergency room) before moving to the IC. The

internal medicine physician has worked 10 years at the hospital (Internal Medicine ward,

Emergency Room and Intensive Care Unit). All of professionals needed at least 3 months in

our Unit, for additional training.

Seguretat - Sistema previst de auditoria de seguretat. Esta previst aplicar les mesures tècniques i

organitzatives necessàries per garantir la confidencialitat i la integritat de les dades, dels

equips, dels sistemes, dels programes, de les instal·lacions i de les persones que

16

intervinguin en el tractament de les dades de caràcter personal, segons les mesures

previstes en el reglament de desenvolupament de la Llei Orgànica de Protecció de Dades

de caràcter personal (LOPD) 15/1999, de 13 de Desembre, per a les dades personals de

nivell de seguretat alt.

- Tercer que fa la auditoria de seguretat si existeix. GeoTrust Global CA

- Certificats de seguretat del servei. *.cannecare.eu public key

Canvis al donar el

servei des de LMS

Conseqüències previstes que es donaran al prestar el servei des de LMS (El servei haurà de

incorporà el logo de LMS en totes les seves pantalles si s’està executant des de Cat@Salut

La Meva Salut)

Afectacions pel:

- Servei. La porta d’entrada al servei serà a través de LMS com a eina oficialment

promoguda per CatSalut per a l’empoderament del malalt.

- Usuaris del servei. Els usuaris poden utilitzar LMS com a single sign-on, i per

tant facilita la seva identificació reutilitzant la de LMS per accedir al servei.

Observacions -