A Strategy to Tackle the Challenge of Chronicity in the Basque Country

A Strategy to Tackle the Challenge of Chronicity in the Basque Country

July 2010

A StrAtegy for tAckling the chAllenge of chronicity in the BASque country

Sufferers from chronic conditions tend to slip under the radar of the health system. this is because for decades the system has been based upon the logic of rescue, of saving lives and so, therefore, has focused on acute illnesses. faced with the increase in chronic illnesses it is necessary to complement this system with one which deals in terms of caring as well as curing, one which offers continuity of care throughout a person’s life, with the added potential of preventing unnecessary hospitalizations and thus reducing costs.

in the forthcoming two decades 26% of all Basques, the baby boomers, will belong to the over 65 age group. for the first time our society must prepare itself for a situation in which those who, today, are aged 50 will have to care for their parents for longer than they have looked after their children. Without major changes in our social policies and in the concept we have of ageing, it will be impossible to face up to the challenges of the current social panorama.

this document proposes what is to be done and the steps to be taken in order to achieve just that in the Basque country.

Medicine and bioscience will bring new discoveries in the decades to come. Many of these will save lives and will be fundamental for chronic patients. however, there are two other significant areas which will change: healthcare to the same degree as biomedical progress and which will also save a great number of lives and which will also be essential for chronic patients. i refer to the advance in information technologies and the organization of services.

the Strategy described in this text values these advances equally to those of the progresses in biomedicine, pointing out that bioscience alone is not enough to face the challenge of chronicity in our societies.

the way the health care system is organized at the provider level will become more and more important as we move forward. it should become as important as the treatments it provides.

furthermore, in managerial terms, it will not be possible to improve the system by focusing only on the internal performance of care organizations. the improvement in coordination between them is even more important. Primary care, hospitals and social services are interdependent. it is necessary for them to find more collaborative and better coordinated approaches. it is in this collaboration in which advances are to be found for chronic patients and in which wide margins for efficiency improvements can be identified which will enable the sustainability of the health system. to this end, it will be necessary to cease to manage structures and to learn to manage integrated health systems, especially on a local level.

in the Basque country we have a public nhS type of health care system. All health care professionals are salaried in both primary health care and hospital care. the important lesson of the past years is that despite this apparently tidy vertically integrated system in management terms, at the provider level this system has not achieved integrated clinical care and continuity of care. Management integration at all levels does not guarantee clinical integration where we need it at the provider level. it is therefore necessary to do something different. this Strategy provides the context to do something different.

Foreword


1

rafael BengoaMinister of Health and Consumer Affairs

Basque Government

the basic premise therefore is to avoid taking any policy decisions which might further fragment care and, rather, ensure we are developing local systems of care which offer continuity of care. consequently, the policy context in the Basque country will strive to build collaboration rather than competition and more concretely, what we propose is not a magic wand, but an organized progression, activating many levers of change.

investment is required in an information strategy and the technology to make it possible, it is necessary to use new approaches to educate patients to manage their illness, to continue to promote evidenced-based medicine, and also to integrate primary care, hospital care and social care and to develop new professions which integrate care.

iit is necessary to manage all these levers simultaneously. coordinated activation of all these levers will provide the required set of tools with which to bring about the necessary change. they are presented here as strategic interventions which will enable us to meet the most complex and important challenge of recent decades: that of organizing a health system worthy of the chronically ill, the most significant challenge of the 21st century.

Although not in all cases, many of these new interventions will bring new efficiencies. they should all however and without exception provide better care and security for chronic patients.

furthermore, many of our management and leadership concepts must change. none of this will be achieved with the kind of leadership we have known in the past. the complexity of the change requires the development of a different leadership approach in the forthcoming decade. With the aim of reaching the necessary alignment between local and corporate level, we are committed to a better distribution of leadership, in which central management create the conditions to promote organization innovations which are inspired by local management and health professionals themselves. it is in this local arena in which the main innovations necessary for chronic patients will be found.


2


3

Introduction 4

The challenge and the opportunity presented by chronicity in the Basque Country 6

2.1 chronicity in the Basque country 7

2.2 the different needs of the chronically ill patient 13

2.3 reference and care intervention models for the chronically ill 14

2.4 What does the evidence say? 18

The need for a system strategy 22

The strategy for the Basque Country 26

4.1 Vision of the future 27

4.2 Policies 30

4.3 Strategic Projects 37

Achieving change: Introduction strategy 60

Accepting complexity 61

top-Down and Bottom-up 62

Index of tables and figures 66

tables 66

figures 67

Content

Photographs: ©M. Arrazola - EJ-GV (Unless otherwise indicated at the foot of the photo)

Edited by Eusko Jaurlaritza – Basque Government – Department of Health and Consumer Affairs.

Dep. Legal - BI-2345-2010

Barring indications otherwise, this study is published under Creative Commons licence (BY)For further information and complete license: http://creativecommons.org/licenses/by/3.0/deed.en

Introduction


5

We often confuse interim short-term tactics with medium term strategies. the former can be found in abundance, the latter are in short supply.

this document provides a framework of action for the medium term transformation of the Basque health System. it is independent but complementary to the interim measures and management policies that have been put in place due to the current economic crisis. While the interim measures attempt to reduce expenditure in the short term in order to ensure sustainability, the final result of this Chronic Patients Strategy aims to outline a new way of organizing care causing an impact on each and every aspect of the system (health results, satisfaction, patient and carer life quality, and sustainability). thus, this structural transformation goes beyond the current economic situation, requiring a long period (at least between 2 and 5 years) before achieving a substantial impact on the system.

life expectancy for the Basque population has extended considerably in recent decades and a significant parallel change has taken place in life styles. one consequence of this is that the prevalence of people suffering from chronic illnesses is increasing to the extent that the great majority of patients in our health system are suffering from one or more chronic illnesses.

The response to the needs of people suffering from chronic illnesses has become the principal challenge faced by the Basque Health System (BHS). these pathologies have a multiple impact: they represent a considerable restraint on life-quality, productivity and the functional state of people who suffer from them; they exert a strong influence on morbidity and mortality rates; and they accelerate the increase in health and social costs, which compromises the medium term sustainability of the healthcare system.

the path towards progress in this area requires a change in the existing conceptual frameworks, within which curing and caring, take place, and one which is clearly outlined in the current health and social policies. The individuals and their environment, their health and their needs have become the central focus of the System at the expense of merely treating the illness.

the existence of a higher number of chronic conditions in a person generally leads to a greater risk of incapacity and mortality, and within the chronic pathologies there are some which are notoriously disabling. this close relationship between chronic illnesses and dependence is the determining factor with regard to prioritizing and indentifying the most suitable health and social policies.

in addition, chronicity implies a challenge to the quality of care provided, as the people who suffer from chronic illnesses are more likely to receive less than optimum care and to suffer adverse pharmacological side-effects.

furthermore, the challenge of chronicity requires proactive measures to combat the health factors which give rise to it in the first place. hence the importance of anticipation, setting up a framework of action which reduces its emergence and progression by means of awareness and preventive actions.

to summarize, chronicity is a in system terms global challenge and consequently requires a systematic response. Beyond particular illnesses or specific groups of sufferers, it is a challenge which must take into account everything from the structural conditions and the lifestyles which contribute to the increase of the pathologies in question to the social and health requirements of the chronically ill patients and their carers: from the initial stages up until the care provided during the final phase of life, including all aspects of care, convalescence, and rehabilitation.

This Strategy aims to improve the health and welfare of all people who are affected by chronic illnesses, as well as to reduce both the level and the impact of chronicity.

The challenge and the opportunity presented by Chronicity in the Basque Country


7

2 .1 T h e c h a l l en g e a n d T h e o pp o r T u n i T y pr e s en T e d by c h r o n i c i T y i n T h e b a s q u e co u n T r y

the prevalence of chronic illnesses increases according to age groups in all cases, but considerably so for those aged over 65, diabetes and osteoarticular pathologies reflecting the highest increases.

in the majority of pathologies, an increase can also be observed in the prevalence among the over 85 age group, especially in the case of neurodegenerative dementias.

comparing the most recent data (eScAV’07) with the prevalence data for chronic problems included in the Basque country health Surveys from 1997 and 2002, it can be seen that the percentage of chronic patients increases in the over 45 age group, which is of particular concern in the current context of population ageing, and, logically, an increase in the more advanced age groups is to be expected in the near future.

According to the Basque health Survey carried out in 2007 (eScAV’07) 41.5% of men 46.3% of women stated they were suffering from at least one chronic health problem. As can be seen in figure 1, the prevalence of chronic problems was higher in women than in men (with the exception of the under 17 age group) and this difference increased with age.

Figure 1

Prevalence of chronic problems according to age and sex

fuente: elaboración a partir de eScAV 2007

100

90

80

70

60

50

40

30

20

10

0<17

Men

Women

18-44 45-64Age

%

>65

Similarly, among the elderly (over 65 years of age) it is not uncommon to find persons with multiple chronic pathologies. Patients with this profile run the risk of suffering some kind of disability or death.


8

Figure 2

Distribution of the population aged over 65 according to the number of chronic problems

Source: Data from eScAV 2007

None

23,4 %

8,6 %

28,9 %

39,1 %

One

Two

Three or more

in fact, the clinical data provide a clear vision of the number of chronic conditions according to patient age, as can be seen in figure 3.

Figure 3

Distribution of patients according to the number of chronic illness by age

Source osabide 2007

80%

70%

60%

50%

40%

30%

20%

10%

0%

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90

95+

2 illnesses

1 illnesses

Age

%

4 illnesses

3 illnesses

6+ illnesses

5 illnesses


9

this multimorbidity reflects conditions which are particularly representative, not least when it constitutes a wide spectrum of chronic illnesses combined in different ways.

Figure 4

Main medical conditions appearing in patients with multimorbidity(3+ chronic illnesses) according to the primary care diagnosis

Source osabide 2007

70%

60%

50%

40%

30%

20%

10%

0%

Hyper

tens

ion

Hyper

lipem

ia

Diabet

es

Arthrit

is

Cervic

al pain

EPOC

Cardiac

isch

emia

Depre

ssio

n

Asthm

aCCI

65%

39%35%

23%18%

13%10% 9% 9%

5% 4%

Chron

ic kid

ney f

ailur

e

from the comparison of the most recent data concerning the prevalence of chronic conditions (eScAV’07) with the data from the health Surveys in 1997 and 2002, it can be observed that the percentage of chronic patients is increasing, above all in the more advanced age groups (figure 5). for example in the case of persons aged between 45 and 64 in 2007, compared to the figure for 1997, there were almost 90,000 more people who declared some kind of chronic ailment.

Figure 5

Change in the percentage of persons with chronic problems between 1997 and 2007 according to their age

Source: eScAV

90

80

70

60

50

40

30

20

10

0<17

2000

2007

18-44 45-64Age

%

>65

1997


10

in fact, a retrospective analysis of certain illnesses reveals that their prevalence is increasing at a considerable pace.

Figure 6: Change in the prevalence of diabetes and cardiovascular disease in the Basque Country

In 15 years the prevalence of chronicity in the Basque Country has increased notably throughout the region

Percentage

Source: eScAV 1992, 1997, 2002, 2007

1992 1997 2002 2007

4,5 - 6,0 6,1 - 7,5 7,5 - 9,0 9,1 - 10,5 10,6 - 12,0

in order to provide a more detailed picture of chronicity in the Basque population a series of illnesses was selected according to the following criteria:

• the principal diagnosed chronic illnesses (neoplasias were not included due to their special characteristics)

• the main causes of mortality.

the following figure outlines the number of chronic patients aged over 18 with each of these conditions, along with their prevalence according to the diagnoses in Primary care. it can be observed that the osteoarticular pathologies along with diabetes are the most common illnesses among the Basque population.

Figure 7

Number (and prevalence) of chronic patients over the age of 18 suffering from the principal pathologies (according to diagnoses in Primary Care)

Source: own data from osabide

117.280 (7,01%)

18.469 (1,10%)

74.402 (4,45%)

172.820 (10,33%)

71.656 (4,28%)

Osteoarticular Pathology

Diabetes

34.154 (2,04%)

33.246 (1,99%)

Asthma

Cardiovascular Diseases

23.153 (1,38%)

22.995 (1,37%)

Neurodegenerative Dementias

COPD

Arterial Hypertension

Hypercholesterolemia

Obesity


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A more detailed analysis on the age distribution of these chronic pathologies indicates that the degree of prevalence is increasing, in almost all cases, considerably so from the age of 65, with the increase being especially notable in the osteoarticular pathologies (>13%) and diabetes, which reaches a prevalence level of above 12%. neurodegenerative dementias become particularly apparent from the age of 85 onwards.

Figure 8

Prevalence of the principal pathologies by age groups (according to diagnoses in Primary Care)

Source: own data from osabide

25,00

20,00

25,00

10,00

5,00

0,00

EPOC

Cardio

vasc

ular

Pre

vale

nce

(%)

Asthm

a

Demen

tias

Osteoa

rticu

lar

Diabet

es

45 a 64

65 or above

18 a 44


12

the study carried out by the Department of health in 2008 “the impact of different illnesses on the health of the Autonomous community of the Basque country” reveals that, among the selected illnesses, those with the greatest influence on mortality rates for men were the cardiovascular and ePoc diseases, which caused 16.4% and 6% respectively of all deaths. in the case of women, cardiovascular illnesses were also the major cause of deaths (17.3%), while diabetes was the second most dangerous (3%).

on the other hand, in spite of not having such a high impact on mortality rates, osteoarticular pathologies are very relevant in as far as disability is concerned. the study estimated that out of all males suffering from a disability, 26.6% could be attributed to this kind of pathology. As for women, the influence of these illnesses on disabilities was even higher, with a prevalence of osteoarticular pathologies among disabled women of 45%.

this situation of prevalence and increasing incidence of chronic pathologies is not a phenomena limited only to the Basque country, but one which is also taking place throughout Spain, with an expected annual increase, according to the prevalence data from the Patient Base of Decision resources, of approximately 1.2% in the number of type 2 diabetics among the Spanish population aged over 20, rising to affect some 7.7% of the population by the year 2016. this increase in prevalence also occurs, to a greater or lesser extent, in a great number of regions throughout the world, being, furthermore a tendency, which according to forecasts, will continue to increase, aggravating even further an epidemiological situation which is already very serious.

Figure 9: Illustration of the forecast for chronic illnesses throughout the world – Example Diabetes

A nivel mundial las enfermedades crónicas tienen las características de una pandemia en expansión.

Source: international Diabetes federation: Diabetes Atlas

2007 2025

4 to <8<4On a global level chronic illnesses bear the characteristicsof a pandemic in expansionForecast of the change in levels of diabetes on a global level(1)

8 to 14 >14

Source International Diabetes Federation


13

2 . 2 d i F F er en T i a l n ee ds o F T h e c h r o n i c a l ly i l l paT i en T

Although chronic illness is defined by a standard list of defined pathologies, it does present a series of differential factors: long duration, slow and continuous progression, it decreases the quality of life of those affected, and frequently reflects a significant level of comorbidity. furthermore, it is a cause of premature death and has significant economic repercussions for families and society in general.

for the purposes of analysis and the approach followed in this document the following list and characteristics have been used.

Beyond the specific chronic illness or combination of illnesses, the focus of these differences is the phenomena of chronicity and the factors involved since its outset, the treatment, be it preventive, curative, palliative, or rehabilitation, up until the final stages, with the chronic patient in the centre of the care pathway. this evolving social construct which we call chronicity encompasses patients with different diseases and at different levels of seriousness. With this in mind, the focus of this document is global and is not devoted solely to specific diseases.

Table 1: list (not exhaustive) of chronic illnesses and their characteristics

Chronic illnesses are very widespread and have certain characteristics in common

Source: health Study and research Services of the Department of health and consumer Affairs of the Basque government

Diabetes mellitus Cardiovascular diseases (Ischemic cardiomyopathy, cardiac insufficiency, cerebral vascular illness)Chronic respiratory diseases (EPOC, asthma) Osteoarticular diseases (rheumatoid arthritis and severe arthrosis) Neurological diseases (epilepsy, Parkinson’s disease, multiple sclerosis)Mental illnesses (dementia, psychosis, depression)) HIV/AIDSDigestive diseases (chronic cirrhosis and hepatopathy, ulcerative colitis, Crohn’s disease)Chronic renal diseases …

Possible illnesses considered chronic Common characteristics

They have multiple causes and complicationsThey normally appear gradually, although they can appear suddenly and present acute statesThey emerge throughout the life cycle though they are more prevalent in the elderlyThey compromise the quality of life causing functional limitations and disabilityThey are long lasting and persistent and result in a gradual deterioration in health They require long term medical care and attentionIn spite of not being immediately life threatening they are the most common cause of premature deathIn some cases they are limited to non-contagious diseases, although more recently they have been included illnesses such as AIDS or tuberculosisFortunately, a significant number of them can be prevented or their appearance can be delayed, while in others, given the level of current communication, their progress can be slowed down and their associated complications reduced The distribution of the conditions and causes that favour the development of these illnesses in a population is not uniform, being the less well-off sectors which present greater frequency. The growing accumulation of risk factors in these less well-off groups will continue to increase the gap in health results

1

2

3

4

5

6

7

8

9

10


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Whatever the particular illness, the most important factors in the interventions in chronic procedures are different to those for acute illnesses.

1. they require a complete diagnosis of the patient including their social situation and their role as opposed to a traditional diagnosis focussed on the illness and the acute symptoms.

2. Proactive, preventive (primary and secondary) and rehabilitation interventions are more important than a typically curative focus on the acute illness.

3. the patient and the carer play a much more important role in the successful outcome of the intervention with the need to change life styles and adhere to these over long periods in contrast to the traditionally passive role of the care receiver.

4. they require a coordinated approach to care with an “individual vision” at all levels of care (primary, specialized, medium stay, mental health, emergencies, social services, health at work, etc.) throughout the duration of the illness as opposed to a rapid and specialized action on the part of a limited number of specific departments.

5. the needs and priorities (medical but also emotional, social, material and even spiritual) of each patient are given more importance considering that we are often dealing with continual interventions over the remaining lifetime of an individual compared to a specific intervention which has a limited impact on a person’s quality of life in the mid-term.

these differences in the focus of the interventions are such that the phenomena of chronicity requires a model of care different to that typically used for acute illnesses.

2 . 3 F r a M e W o r K s a n d c a r e i n T er V en T i o n M o d el s F o r T h e c h r o n i c a l ly i l l

currently there exists, at a global level, a broad base of highly developed theoretical models. in addition, in recent years, specific interventions have been outlined, the efficacy of which can be tested as they have been carried out in various health systems in different parts of the world. Specifically, in this section the main reference models have been included (ccM, iccc, kaiser Pyramid of care, the king’s fund Pyramid) along with some examples of interventions with scientific evidence.

Probably, the outstanding international reference model for chronic patient care is the Chronic Care Model CCM developed by ed Wagner and by collaborators from the Maccoll institute for healthcare innovation in Seattle, in the uSA.

in this model, care for chronic patients takes place on three overlapping levels: 1) the community with its policies and multiple public and privates resources; 2) the health system with its supplier organizations and insurance schemes; and 3) the interaction with the patient in the clinical practice.


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Table 2

Adaptation of the care model for Chronic Patients in the Basque Country

Source- Developed by ed Wagner and collaborators from the Maccoll institute for healthcare innovation. Adapted by o+berri

Basque institute of health innovation

Community, Resources and

Policies

ActivatedInformedPatient

ProactiveHealthTeam

ProductiveInteractions

Medical and functionalresults

Health systemOrganization of health system

Self-management

Design ofprovisionsystem

Decisionsupport

Medicalinformation

systems

this framework identifies six essential elements which interact among themselves and which are key to achieving optimum care for chronic patients. these are:

• organization of the healthcare system.

• Strengthening of links with the community.

• fostering and support for self-care.

• Design of the care system.

• Decision making support.

• Developing clinical information systems.

the final objective of the model is that active informed patients become the protagonists of the medical encounter along with a team of proactive professionals with the requisite capabilities and skills, all in pursuit of a high quality level of care, increased satisfaction and improved results.

Standing out among the adaptations of the ccM is the model proposed by the World health organisation, known as “The Innovative Care for Chronic Conditions Framework (ICCC)”.


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Table 3

The Model of Innovative Care and Chronic Conditions (ICCC)

Source: Who

Patient andfamily

Com

mun

ityAg

ents

Health Care

teams

Prep

ared

Informed Motivated

Better results for chronic conditions

Community

Awareness and taking away stigma.

Promoting better results through leadership and support.

Mobilization and coordi-nation of resources.

Provision of complemen-tary services.

Health Organization

Fostering continuity and coordination.

Promoting quality through leadership and incentives.

Organization and funding of the health care teams.

Use of information systems.

Support for self-care and prevention.

Framework of Positive PoliciesStrengthening of alliances • Development and assignation of human resources • Policy integration

• Support from the legislative framework • Guarantee of suitable financing • Leadership and support

this model adds to the ccM a model health policy perspective of which the main ideas are the following:

• Decision-taking based on evidence

• focus on the health of the population

• focus on prevention

• emphasis on the quality of care and on system quality

• flexibility/adaptability

• integration, as the hard fractal core of the model

Apart from the system models such as ccM and the iccc, the other type most frequently used is that which refers to population models, the focus of which is the population as a whole and its needs instead of those of the health care system. Standing out among these is the “Kaiser Pyramid” which identifies three levels of intervention depending on the level of complexity of the chronic patient. in posterior interpretations to the kaiser model the population aspect of promotion and prevention has been included. the main idea set out by the kaiser Pyramid is one of segmentation or stratification of the population according to its needs:

in the patients with more complicated cases with frequent comorbidity an integral management of the case is required with the provision of fundamentally professional care.

• high risk patients but whose cases are less complex as far as comorbidity is concerned receive a disease management approach which combines self-management and professional care.

• the majority of chronic patients with conditions which are still incipient receive support for the self-management of their illness.

• finally, the general population is the focus of promotion and prevention actions which aim to control the risk factors which might contribute to the development of chronic illnesses in individuals.


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Table 4

Extended Kaiser Pyramid

Source: kaiser Permanent. Adapted

Promotion and Prevention

CaseManagementSelf-care

Professionalcare

Patients withsevere complications (5%)

High risk patients (15%)

Chronicpatients (70-80%)

General Population

IllnessManagement

Self-management support

one of the most interesting adaptations of the kaiser Pyramid which has been put into practice is the pyramid defined by the king’s fund in the united kingdom. in this adaptation what stands out is the combination of the health and the social vision as two integral parts of the care requires by a person.


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Table 5

Pyramid defined by King’s Fund in the United Kingdom

Source: king’s fund (c.ham)

Level 3Case

Management

Individuals with highlycomplex needs/morbidity;

improve the care for chronic patients;separate them from acute care

Higher risk patients;specific interventionsto combat the illness;

early diagnosis

70%-80% of individuals;health promotion;nutrition; exercise

Support peoplewho have more needs at home;

take them away from permanent residences

High quality supportto carers at home

Appreciate people’s value;investment in voluntary

prevention services

Level 2Managingthe illness

Adapt the service to the individual

Pyramid de�ned by King’s Fund in the United Kingdom

Social vision Health vision

Level 1Self- Management

2 . 4 W h aT d o e s T h e e V i d en c e s ay ?

As well as conceptual frameworks of action, there have also been interventions in recent years which have offered scientific evidence of their effectiveness, revealing the possibility of improving results at different levels (health results, patient and carer satisfaction and quality of life, sustainability) by changing the way of managing chronic illnesses. nevertheless, the majority of these interventions have been carried out in particular health systems and their extension and adoption by other systems has been limited and difficult. this only underlines the complexity associated with the implementation of these interventions and the change in systems to the level required by the model.

Among these interventions a significant number have shown improvements in patient and carer satisfaction levels (e.g. care coordination, case management, telemedicine).

in relation to the results corresponding to health outcomes and efficiency improvements there are fewer specific examples with clear evidence (e.g. case management by nursing – Boyd/Boult). however, the systems which have given clear backing to these kinds of models (e.g. kaiser Permanente in the uSA, Jonkopping, in Sweden, various area health authorities in england, canada, new Zealand and Scotland) in general demonstrate better health outcome results than comparable institutions with a high level of efficiency.

for the design of this Strategy for tackling the challenge of chronicity in the Basque country we have taken into consideration:

• the reference of the models outlined above, as well as the interventions which have proven to be effective.

• the collaboration of the international centres of excellence mentioned above, many of which were represented at the international congress organized in Bilbao (2nd-3rd June 2010) with the objective of contrasting and comparing their experiences with the strategic proposal designed for our situation.


19

• the thorough national and international analyses of all the evidence relating to the management of chronic illnesses.

We include below in the section “ the relationship with health Systems Sustainibility “ a summary of the most significant conclusions of these analyses1.

it is important to highlight that the evidence in favour of the interventions indicated in this Strategy is growing, indicating that there are numerous opportunities for the Basque health System.

indications are that investments in this line of action in general will be beneficial for patients, will be cost-effective, will reduce the number of hospital admissions, that they will improve efficiency and will reduce the mortality rate.

The relationship with Health System sustainability

the basic notion resulting from these studies with regard to efficiency can be resumed as follows:

• it is necessary to organize a system which is able to deal with comorbidity and not merely to deal with one illness at a time, (35% of people aged over 80 suffer from two or more chronic illnesses).

• the most significant potential benefits arise from the prevention of the unnecessary admission of complex patients into the hospital system.

• the cases which activate a sole intervention (e.g. remote medical monitoring from home, or training patients for self-management) may not achieve the desired efficiency impact. to obtain efficiency improvements, it is necessary to systematically intervene, working several levers of change, using the models outlined above in an integrated and coordinated fashion.

• economic results will appear in the mid term.

• it is worth “noting down” the management interventions of chronic patients according to the predictions of high use (e.g. recent hospitalization, frequent use of emergency wards, certain medical indicators). By acting in this way, saving opportunities will be substantially enhanced.

• individualized planning previous to admission and advice from multi-disciplinary teams guarantees substantial reductions in avoidable re-admissions, even in the absence of other interventions.

• When patient groups are easily identifiable and classifiable, face-to-face interventions which combine education with clinical care including contact with primary care or hospital specialists, as well as remote electronic monitoring are considered worthwhile in efficiency terms. consequent reduction in use and expenditure tends to be positive.

• intensive and individualized education combined with treatment is more effective with diabetic patients (with the exception of the elderly) and with asthmatic patients.

• interventions based on opportunistic education during the patient-doctor interaction tends to be less effective compared to highly intensive educational interventions focussed on patient self-management.

• interventions for the management of congestive cardiac failure and for the elderly with multiple conditions have proved to be the most fertile area for achieving health improvements and relevant economic savings.

• Studies confirm an positive return on investment in congestive cardiac diseases, asthma, and with patients with multi-pathologies. the main saving would be in the fall in admissions and readmissions as well as in daily costs.

1 Chronic Disease Management: Evidence of Predictable Savings; J. Meyer and B. Markham. 2008


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• in asthmatic patients the saving is substantial due to the reduced use of the emergency services.

• in chronically ill patients who were treated more intensively and individually, the fall in hospital admissions was from 21% to as high as 48%; with asthma patients in particular, the fall in admissions ranged between 11% and 60%. in diabetics hbA1c values dropped by 1% and hospital admissions fell from between 9% and 43%. Among elderly patients with multiple pathologies the fall in hospital admissions was from between 9% and 44 %.

Although the evidence on the impact of the management of chronic care is heterogeneous and generalizations should be carefully evaluated, the overall analysis indicates that significant and foreseeable savings could be achieved.

this data confirms the growing interest in this line of work to ensure the SuStAinABility of the Basque health System.

therefore the new Strategy for the Basque health Service has been designed along these notions.


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The needfor aSystem Strategy


23

As has been discussed in the previous section, in the Basque country, chronic illnesses represent the dominant epidemiological situation of the country. it is estimated that they currently represent 80% of the interactions with the Basque health System and account for more than 77% of health expenditure. however, the basic characteristic of the current care model is reactive, in which the patients have an episodic relationship with the health system and this logic is not what chronic patients need. in fact the current System is designed and structured to comply with an epidemiological model focussed mainly on acute interventions which do not correspond to today’s needs. furthermore, there is a lack of integration between the health system and the other social resources associated with health, which, as has been seen, is of substantial importance for chronically ill patients.

the structural tendency towards the increasing relevance of chronic patients means that it is absolutely necessary to respond to their needs, both from the point of view of health results and in order to guarantee the sustainability of the system in a situation in which there is increasing pressure on expenditure.

Based on the above (epidemiological challenge, chronic patient needs, international evidence….), this Strategy has been drawn up in order to adapt the Basque health System to the current demands and those of the future in areas of prevention and care for chronic illnesses. it is important to point out that this strategy is not a repudiation of the excellent management of acute illnesses, but one which complements the current acute organisation with the capacity to also respond adequately to the needs of chronic patients:

1. the challenge of chronicity goes beyond the illness and the symptoms, so the Strategy needs to broaden its vision of the individual: not only their biomedical situation but also their social and functional situation.

2. tackling chronicity also requires overcoming the conventional programmes of episodic treatmen. it is necessary to try and reduce the appearance and the adverse effects of chronic illness by means of a population approach in which prevention and health promotion are key elements.

Table 6: The reactive nature of the current system

The health system is still mainly reactive

Source: own elaboration

Population has notbeen stratified...

We do not havecase nurses...

We do not haveroutine medical

reminders...

Care is fragmented... Patients arenot activated...

The patients who couldbe are not telemonitored

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3. the patient and their carer cannot be passive elements in this strategy. they have a central role which requires training and an increased awareness beyond that of their traditionally passive role.

4. chronicity requires a holistic vision of the patient and an all-embracing and coordinated focus both from within the health system (primary, specialized, medium-stay, mental health, emergencies) and from beyond, embracing the institutions, Departments, Programmes and available technologies and infrastructures directly related to chronicity (social assistance, sport, health at work).

5. finally, chronicity requires that the range of available interventions is widened and adjusted to the needs and priorities of the patients in each of the phases of their illness (from the outset to the end of their lives, embracing convalescence and rehabilitation).

this new strategic approach is supported by international trends and by the increasing evidence of the effectiveness of the interventions and models mentioned in the previous section, more in tune with the needs of chronic patients.

All in all, the Strategy is presented as an opportunity for change in the model to one in which the agents involved participate in the establishment of a framework of action for an integral management of chronicity from the population perspective, building upon the existing capabilities of the system. the following table shows a series of emerging elements which complement the existing model in the interests of achieving the aforementioned change.

Table 7

Towards a new model for the Basque Health System

Current Elements Emerging Elements

Accessibility face–to-face remote

Product health services health value

Architecture Supplier focussed citizen focussed

Quality of Service and of Management of the System

Care Model

• episodic

• reactive

• hospital focussed

• continuous and coordinated

• Proactive

• integrated

Value Proposal • Accessibility

• focussed on care

• health

• Prevention, cure, care and rehabilitation

Source: osaberri


25

The strategy for the Basque Country


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the strategy designed for the transformation of the Basque health System along the lines mentioned above is structured in the following way:

• it is based on a medium term Vision, which defines and describes the desired future situation.

• it describes the health care Policies for chronic patients as guidelines for the successful fulfilment of this vision.

• finally, there is a series of Strategic Projects which contribute towards generating and implementing the change to make the policies and the vision a reality in each one of its dimensions.

4 .1 V i s i o n o F T h e F u T u r e

the Basque chronic Patients Strategy aims to respond to the needs generated by the phenomena of chronicity in all the affected groups: chronic patients and their carers, health workers, and citizens in general.

• for the chronic patients and their carers it will mean changing from a reactive system to a proactive system which will offer them a more integrated level of care (coordination between health levels and alignment with the social and employment agendas), more continuity during the development of the illness (from prevention to the end of life, including rehabilitation) and be more adapted to their needs. furthermore, they will be given a role to fulfil and greater responsibility in the management of their own health. All with the final objective of being able to offer patients better health results, with greater levels of satisfaction as far as care and quality of life are concerned.

1 - Vision

2 - Policies

3 - Strategicprojects

Table 8 Strategic Diagram


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• for medical professionals it will represent the possibility of devoting more time to work on issues of higher added value and having access to the necessary tools (e.g. more complex diagnostics in primary care, tools to support changing patients behaviour). furthermore the idea is to that the time invested in routine work will be automated (e.g. prescriptions for long term treatment, coordination of the clinical history between levels of care, basic health advice by telephone, case management by nursing) and the tools will be given to the patients themselves or the carer.

• for citizens there will be a double benefit. As tax payers they will benefit from a more efficient use of the systems resources, with the type and cost of each intervention being adjusted to meet the attention and care needs of each case, thereby contributing to the sustainability of the system. As potential chronic patients, they will participate in the prevention of chronicity and the promotion of their own health, avoiding the development of chronic conditions or at least reducing their impact on their health and quality of life.

• for non-medical professionals and health service managers it will mean that their role will be given more recognition, they will have confirmation of their impact on health results and not only on the efficiency of the system, their co-leadership will be broadened, they will witness the breaking of barriers which limited their area of action and responsibility, as well enjoying the opportunity to share with other professionals new areas of influence and collaboration.

Basque Health system adapted to

deal with Chronicity

HealthProfessionals Citizens

Chronic Patients and their Carers

More time for workwhich has greateradded value

Fewer routinejobs

E�cient use of resources

Prevention of chronicity and its development

Better health results

Greater lifesatisfaction and quality

VisionVision

Table 9: Vision of Strategy for Chronic IllnessesThe Strategy for Chronic Illnesses aspires to substantially improve the lives of patients and carers, health professionals and citizens


29

this change will have an impact both on Primary care and on hospital care. it is not a question of deciding where care should be provided, but accepting that care for chronic patients nowadays is suboptimal mainly due to the lack of care continuity between our levels of care. thus the logic of this Strategy is based on the premise that we are faced with a problem of organization of clinical and preventive practices, both with regard to primary care and hospital care.

care provided is still basically reactive to acute illnesses and episodes; that is, in a model of acute illnesses the premise is to define the problem which is the subject of the clinical consultation, to diagnose it and to initiate a treatment, usually pharmacological. the consequence of this model of organization is that, when it is applied to a chronic patient, that patient receives care which is more episodic than continuous, as this is how the system has been conceived. Moreover, the consultation is normally determined by the acute problems from which the patient is suffering. All this leads to a reactive model.

By contrast, we propose moving to a model of organization which is more proactive in order to ensure:

• that patients have the confidence and the skills to manage their illness.

• that patients receive care that provides optimum monitoring of their illness and prevents complications.

• that there is a continuous monitoring system both remote and face-to-face.

• that the patients have a self management plan, which has been mutually agreed with health professionals, with which to control their illness.

• that we develop an organization with a preventive and continuous care logic, which is designed between the patient and the clinical team.

experts agree that it is preferable to manage chronic illnesses in primary care, and the models outlined in Section 2.3 of this document are based upon this logic. this strategy continues this line of work, but it indicates that hospitals should also be innovative in their management of chronic patients, as in many cases they have to be admitted to hospital. thus hospitals play a fundamental role, as treating chronic patients during their acute episodes is part of the integral management of those patients.

finally, what we are dealing with is a process of change which combines uniform elements for all patients and agents of the system – an essential ingredient to guarantee the necessary level of standardization in an ambitious strategic change – with the necessary adaptation of various local situations arising from users and service organizations. for this reason, we defend the need to better balance the dichotomy between the corporative and the local perspective. that balance is achieved with certain global strategic frameworks, which emanate from the centre and extend uniformly throughout the system and with the necessary local freedom required for local application. this balance is further explained in the last chapter of this strategy.

to realize this vision, it is necessary, not only to provide the system with the necessary tools, but also to change substantially the “way of doing things”, with respect to the organization of care; a change to be made both by the patients themselves and by the social and health care professionals and managers. these changes are defined in the five Policies of care for chronic patients explained in the following chapter.


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4 . 2 p o l i c i e s

the policies described below correspond to the principal areas requiring change in order to be able to suitably address prevention, care, rehabilitation and health care for chronic patients. As has been previously mentioned, these polices do not aim to replace the current system of handling of acute illnesses, but in fact to complement it in order to be able to offer excellent and efficient care to chronic patients. to put each one of these policies into action, it will be necessary to strengthen the system in various areas, in order to prepare a more adapted model geared to managing the phenomena of chronicity. this section will focus on describing the aim and expected results of the policies, while details of the concrete strategic projects can be found in the following section.

POLICY I. Adoption of a population health outlook, stratified and proactive population

health management and reduction of inequalities in health matters.

Objectivethe objective of the focus of population health is to improve the health of the entire population and reduce the potential level of health inequality. this focus will also enable the analysis of the complexity and comorbidity levels of the population, and its segmentation with the aim of targetting resources to cover the different needs in a tailored and proactive way.

Context and Focus this policy recognises both the diversity of the social, economic and environmental factors which influence the development and evolution of chronic illnesses, and the behavioural factors which affect health. it also helps identify how these causes determine the inequalities.

in this way the specific needs of the different levels of the patients in question are responded to: from those who are in the final phase of their lives (receiving palliative care) to those who, although not yet chronically ill, present a series of risk factors which identifies them as potential chronic patients in the future; as well as recognising and facing up to the specific requirements of population groups such as the elderly and those who find themselves in a precarious social

Focus on strati�edpopulation health

I

Promotion and Preventionof chronic illnesses

II

Responsibility and autonomyfor patients

III

Continuous carefor the chronic patient

IV

E�cient interventions adaptedto the patient’s needs

V

PoliciesPolicies

Table 10: PoliciesHealth care for chronic patients will change with the introduction of five strategic policies



31

or economic situation (the groups most affected by chronic illnesses and in need of specific social interventions).

focussing the policy in this way, the prevention and care for chronic illnesses must respond to the needs of the people from all backgrounds, both cultural and linguistic; of every age, from children to the elderly; from all socio-economic classes; from all areas, both rural and urban, and with no disparity between men and women.

Specific Resultsthe result of this policy will be to identify the “target” groups of patients for certain interventions. this requires both a stratification of the population according to their clinical risk and their health and socio-health needs, and also the association of each level of stratification and patient typologies with the kind of interventions that evidence has proven to be effective for chronically ill patients in the Basque country. eventually, this will all be integrated in information systems and in the daily clinical duties of the medical professionals, thereby personalising the treatment received by each patient.

this integration is fundamental, as the stratification of the population and the population focus which it enables is a first essential step towards setting in motion the rest of the chronic illness management policies.

furthermore, stratification will help bring about the change in mentality from a “patient” focus to a “population” focus which considers the individual beyond the acute episodes and also embraces prevention, rehabilitation, and medium-term care.

Level 4

Level 3

Level 2

Level 1

Patients with severe complexityRequires urgent health care coordination

Patients with medium level complexitySuffer from complications and need

a certain level of managementPatients with reduced complexity

Well managedRecently diagnosed

Patients with no chronic illnessesHealthy population

Prev

entio

n ac

tiviti

es

Table 11Diagram of a possible pyramid of population stratification

Source: Adaptation of the kaiser Permanente risk stratification


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POLICY II. Prioritisation of health promotion and the prevention of illness.

ObjectiveA considerable number of chronic illnesses and their risk factors can be prevented and, consequently avoided. once they are present, their early diagnosis and detection often enables their progression and their negative and disabling effects to be limited. the objective of this policy is to create a framework of action, including proactive prevention measures and health promotion actions with regard to chronic illnesses, aimed at the different levels of the population pyramid: both for the healthy and for those persons with risk factors, as well as those who are already suffering from one or more chronic illnesses, but always emphasising an integral population approach.

Context and focusSpecifically, some risk factors such as the consumption of tobacco, alcohol, or other drugs, lack of physical activity, a badly balanced diet or unhealthy working conditions can be controlled, thereby avoiding the appearance and progression of a high proportion of many chronic illnesses.

the aim, therefore, is to put tried and tested measures and interventions into action with the aim of preventing chronic illnesses. interventions will be combined both at an individual level and at the level of patient groups and risk groups. the proposal of specific interventions for health promotion and prevention of chronic illnesses must, necessarily, take into account the available scientific evidence. thus, the use of information systems and risk stratification of the attended population may be of great benefit when it comes to carrying out interventions at a more efficient level.

health promotion actions must be aimed at raising awareness and informing the citizens about their health, at improving their lifestyle habits, at raising their awareness with regard to certain risk factors. As far as prevention actions are concerned, these must be introduced both at primary and secondary level care, stressing the usefulness of early detection in primary care and the capacity for contention of progression of the illness in secondary care.

Specific results resulting from the policy will be an integrated set of prevention and health promotion actions of proven effectiveness in the Basque country, both at primary and secondary level, aimed at target groups of patients according to the results of the stratification. these actions should significantly reduce the prevalence of chronic illnesses and the deterioration in health of those patients who suffer from them.

POLICY III. Promoting the active role of the citizens, encouraging their responsibility in the management of their disease and in patient autonomy

Objective

Promoting the increasing role of the citizen in dealing with chronicity. on the one hand, with self-care on the part of the chronic patients and their carers, as an essential lever to reach personalised based care with the necessary support of the healht care system at all levels. Self-care requires the active participation of the patients and their carers in administering healthcare and in the process of making informed decisions which are agreed on with the doctor, the patient and the carer. on the other hand, it requires their active participation in their own health promotion and the prevention of the appearance and development of chronic illnesses.


33

Context and focuscare which is focussed on the individuals places them at the centre of their own health care, converting them into active patients and administrators of their own state of health. however, the traditional role of the patient and the carer in the health system is passive with all the responsibility and knowledge centred on the doctor. this traditional role is up to a point coherent from the point of view of acute illnesses in which immediate and decisive action is required in the case of a complex episode in which the patient only occasionally participates. A chronic procedure, however, has long reaching effects and requires intervention over a long period of time. Moreover, the patient or carer has considerable influence over the effectiveness of the treatment and the progression of the illness depending on the rigour with which the treatment is adhered to and the lifestyle of the patient (e.g. tobacco, exercise, obesity).therefore, it is crucial to change the conventional role of the passive patient, receiving care from the system, to that of an active patient/citizen, accountable for their own care and illness prevention.of course, the degree of participation and accountability of patients and carers is different, depending on the type and complexity of the process, the level of independence, and the social-health situation of the patient. in any case, all patients and carers have the opportunity to participate in their care to an extent, as patients can be supported in the development of specific skills and resources in order to maximize their capability for self-care.

Specific results the specific result of this policy will be an array of interventions and tools which will enable self-management and promote the accountability of patients with regard to their own condition. these interventions and tools will be incorporated into the daily clinical routine of the health professional –and in that of the social workers when relevant- and will be easily accessible and extensively used by the patients and their carers, with the support of patients associations. the eventual consequence will be a stricter level of adherence to the treatment and lifestyles necessary to control and prevent the illness, and a more efficient use of the resources of the health and social systems.

POLICY IV. To guarantee continuous care through the promotion of a multi-disciplinary care programme, co-ordinated and integrated between the different services, care levels and sectors.

Objectivecare for citizens suffering from chronic pathologies involves numerous health care providers in different scenarios, such as Primary, Secondary and tertiary care, medium and long stay rehabilitation centres with a focus on acute and sub-acute cases, mental health centres, the social-health sector, health at work, community organizations and ngos, etc.

integration and continuity in the provision of care are essential elements with which to guarantee that the necessary services are received at the right time and in the right way, optimizing health results and improving the experience of “the journey through the system”, in a process which begins with initial prevention and goes beyond the worsening of a chronic illness until the point at which rehabilitation permits the citizen to resume a normal life. from the professional point of view, the target is to promote coordination to avoid duplication and to reach optimum management with regard to transitions between care levels.


34

Context and focus this requires a flexible system, capable of coordinating services, suppliers, locations and sectors over time. this, in turn, requires a commitment from all actors and the capacity to work in a team in order to achieve common objectives.

the provision of services must be programmed and coordinated in order to attend to the needs of patients and carers, in accordance with quality standards and clearly defined care procedures (e.g. promoting the application of medical guidelines). the existence of multidisciplinary teams, shared care tasks, skill training for professionals, and the taking on of new roles are fundamental to ensure the effectiveness and the continuity of patient care.

in short, the key for a system organized to improve planning, integration and continuity of chronic patient care should revolve around:

• the coordination-integration of care measures.

• the promotion of multidisciplinary teams.

• the development of a model of subacute hospitals.

• Strengthening the role of Primary care.

• care planning.

• the design and effective introduction of new professional roles and profiles.

• Strengthening rehabilitation as a key pillar in the system.

Specific results the specific result of this policy would become evident in all those mechanisms, roles, social - health care agreements, clinical procedures/protocols/paths and tools which are necessary to guarantee continuity of care for the chronic patient between the different people and organizations involved, both health and social, and in particular during the transitions between different levels of service. in a practical way, virtual multidisciplinary teams would be set up which would share information and diagnoses in a transparent fashion. the eventual consequence for the citizen would be care which was better adapted to their needs and their situation within the cycle of the illness (from prevention to rehabilitation), a product of the integrated vision of the information and the reduction of the number of unnecessary interactions, caused by the lack of coordination between care levels, while the health professionals and social workers take on new roles which will enable them to focus on improving the health and the situation of the patients, and to avoid repetitive work and carrying out tasks of minor added value.

POLICY V. To adapt the health interventions to the needs and priorities of the patient and the efficiency of the system.

Objectiveto develop a patient centred system which chooses the optimum health intervention from a wide range and adapts it for the chronic patient in each situation, taking into account:

• in first place, the needs and priorities of the person, bearing in mind that behind each medical record there is an individual with a series of personal, emotional, social and psychological needs, seeking the most humane care and that which is less aggressive, disruptive and intrusive for the life of the patient (e.g. a ten minute visit may require up to four hours of disruption in the patient’s life) with special emphasis in the case of those patients in palliative situations.

• in second place, the needs and priorities of the patient, their carers and their environment, with an integrated vision of their pathologies, progress and previous


35

interactions with the health care system, searching for the intervention which would achieve the best health results.

• in third place, the needs of the health care System itself, ensuring an efficient and responsible use of resources at all times, guiding the patient towards the least intensive level in technology and care, compatible with their medical situation and also seeking alternatives to reduce the burden on activity and economic resources.

Context and focusthere is growing evidence which indicates that the best results of a system require taking steps beyond mere medical considerations of the situation of the patient; that is, the taking into account of their priorities, involving them in the decisions and choice of treatment. We must move towards a healthcare model which reduces the level of intrusion of healthcare action in the daily life of patients.

furthermore, technological and management advances have enabled the extension of the range of health interventions available beyond the traditional doctor’s appointment. telecare, telephone consulting, internet consulting, electronic prescription… are just a few of the examples of current alternatives available for a health service, which are promoting the home as the main location for the provision of health and social care for chronic patients, with the increase in programmes such as home based hospitalization and other forms of home care.

Moreover, the growing and unstoppable pressure on the system, both in terms of health service activity and in terms of the limitation of available economic resources, calls for the need to search for more efficient interventions which do not diminish the level of care, patient satisfaction or the clinical results.

All this is particularly important for the chronically ill who have a continuous interaction with the system throughout a period which could last several decades. these patients need particularly humane and less intrusive treatment, as their relationship with the System will not be a one-off or occasional episode but an integral part of their lives. And it is these patients which the system needs to treat in the most efficient way possible, as they make up a disproportionate part of its activity, and they have some needs which are different to those of acute patients, with less need for curative intervention and more need for monitoring and rehabilitating interventions.

for this reason, the aim is to introduce new kinds of interventions, to reinvent and adapt the current ones and readdress the balance of the different available services. the aim is also to take advantage of the understanding of the stratified needs of the patient and the unique social and health vision of each person and their interaction with the system, aspiring to a situation in which each patient receives at all times the intervention which best fits their needs and priorities as a person, as a patient and from the point of view of the efficiency of the health system.

Some specific examples are: the introduction of the possibility of interacting virtually with the system in order to obtain a more practical and quicker response: an increase in emphasis on rehabilitation actions with innovative rehabilitation programmes (e.g. collaboration with sports centres), electronic prescription which avoids the need to make trips to health centres to pick up long-term treatment prescriptions, home based hospitalization or in sub-acute hospitals for all patients whenever it is medically compatible, lessening the impact of care on a person’s life as well as reducing the cost for the System (e.g. a bed in a hospital for acute treatment can cost twice as much as one in a sub-acute hospital, without providing the chronic patient with a lower level of care due to the diagnosis).


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Specific Results

the specific result of this policy will be a systematic adaptation of the different interventions to personal needs and priorities, both those related to health and to the system, in such a way that interventions will neither be more intrusive nor more costly than strictly necessary, and furthermore, the decision regarding intervention will be increasingly shared between the professional and the patient. in practical terms, it includes the substitution of face-to-face interventions for remote or automatic interventions whenever possible, adapting the level of care (e.g. beds for acute patients, beds for long stay, home hospitalization), promoting rehabilitation and preventive interventions and reducing unnecessary visits. the eventual impact will be greater satisfaction levels both for patients and for professionals, greater quality of life, better health results and comparatively lower costs.

Cost per action / stay€/day

0€

Self care

Telephone consultation with doctor

Appointment with nurse PC

Doctor’s appointment

PC

Appointment with specialist

Case management

Home hospitalization

Mid-term hospitalization

Chronic hospitalization

Care for basic simple needs Medical analysis and intermediate

care

Complex diagnoses PC

Specialized complex

diagnoses

Interaction of care and integral

management

Basic medical monitoring

Intermediate medical

monitoring

Advanced medical

monitoring

Minimum Limited 1-3 hours to including travel and appointment

2-5 hours including travel

and appointment

Periodic contact

Changes at home and frequent

visits/contacts

High level of disruption

Very high level of disruption

<10€ 25€ 35€ ~50€ 100-150€50-200€

400-500€

Level of attention

Level of disruption for the patient

700-900€

Table 12: Interventions adapted to the patient’s needsIt is crucial to adjust the type of intervention to the needs of the patient so as to ensure an efficient use of resources

Source: estimates made by osakidetza, data from osabide and international examples, own elaboration


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4 . 3 s T r aT e g i c pr o J e c T s

A series of Strategic Projects is currently being launched to an advance towards the policies outlined in the previous section, building progressively a new model for chronic illness for patients, professionals and citizens in general.

PopulationFocus

1 Stratification and targeting of the population

Adapted interventions

11 OSAREAN: Multi-channel Centre

12 e-prescription

13 Chronic illness research centre

Continuityof care

5 Unified Medical record

6 Integrated medical care

7 Development of sub-acute hospitals

8 Advanced nursing responsibilities

9 Socio-health collaboration

10 Financing and contracting

Patient autonomy

3 Self care and patient education: Active Patient – Paziente Bizia

4 Setting up a network of activated patients, connected through the adoption of new Web 2.0 technologies by the Chronic Patients Associations

Prevention and Promotion

2 Interventions aimed at the principal risk factors (e.g. giving up tobacco, prescribing a healthy life, care for the elderly)

14 Innovation on the part of the medical professionals

VisionVision

Strategic Projects

Table 13: Strategic Projects within the Chronic Illness StrategyPolicies are introduced by way of 14 strategic projects

Source: estimates made by osakidetza, data from osabide and international examples, own elaboration


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STRATEGIC PROJECT 1. Stratification of the population the proposal of this project is to provide the Basque health service with an instrument with which to stratify the population in prospective way, according to their health care needs.

currently, a research study is being carried out, the objective of which is to establish the validity of different models for predicting the demand for health resources and categorizing the citizens in levels according to their requirements for health care in the future.

the predictive models which are being analyzed incorporate demographic, socioeconomic and medical variables as well as those relating to

the previous use of health services. to develop the information further, information proceeding from other data bases is also used, such as the hospital cMDB, the annual classification of primary patients in case-mix, digitalized records of specialized care, Department of health prescriptions and census data.

it is estimated that the study, which includes all the non-pediatric population,who receive care from the Basque Health Service, (Osakidetza), is estimated to be finished by the end of 2010.

the conclusions of the research will enable mechanisms to be established for the stratification of the population and, thereafter, the design of specific interventions for the different patient groups, adapted to their degree of need.

to successfully integrate this project in day to day practice the process will be systemized. in this way, information from the stratification of the population will be easily accessible and it will be feasible for different clinical and management groups to make use of it for the efficient carrying out of their function.

Flagship target

Calendar – Principal milestones25Marzo

Expected Impact

Operative strati�cation of the Basque Population, systemized and recurring from 2011 onwards

To establish a prospective model of recurrent strati�cation of the population, according to the care requirements and future demand for resources, enabling the design of speci�c actions for each group, with particular emphasis in those su�ering from multi-pathologies (mainly chronic patients)

Requesting Data and setting up data bases

Comparative analysis of potential models

Choosing model and initial applica-tion

Choosing Segments and designing actions

Systemization (in de�nition)

Using Information (in de�nition)

Jan – June 2010 June – Nov 2010 Nov 2010 –Feb 2011

March 2011 onwards

1 Strati�cation of the Population

Table 14: Strategic Stratification Project



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STRATEGIC PROJECT 2. Prevention and promotion interventions on the principal risk factors this strategic project aims to construct a common framework for the prevention and promotion interventions concerning the principal risk factors related to chronic illnesses. Within this framework will be grouped the various specific interventions; both those which are centrally organized (e.g. tobacco regulation), and those which are the initiative of the clinical level (e.g. Prescribe Vida Saludable- Prescribe A healthy life, prevention of type ii diabetes or the preventive actions aimed at the elderly) and those which offer evidence of being effective for their implementation in the Basque country.it also incorporates collaboration, beyond formal health services, with the rest of the government organizations (e.g. sports promotion), with patients associations and with the third sector.the key to the success of this project is the initiation of the programmes for citizens at risk. in this context it is necessary to develop a range of more sophisticated communication techniques, including new forms of communication (e.g. social marketing, education workshops, etc). An intervention example: Prescribe A healthy life (Prescribe Vida Saludable) the objective of the Prescribe A healthy life project is to optimize the promotion of physical activity, balanced diet and the giving up of tobacco in the context of primary care. it is a research-action project in which professionals of all areas, together with researchers, develop and assess innovative interventions aimed at modifying the aforementioned behaviours. it requires changes in the organization and the operating procedure of the centres involved in order to redirect their focus towards health promotion with the cooperation and the use of resources from sectors from outside the health sector. the work plan is divided into progressive phases: (1) modelling phase based on the new “healthy life Programme” in the intervention centres (2010), (2) piloting to see its feasibility and its potential effectiveness (2011-2012) and (3) dissemination of the programme and assessment of its impact on the population (2013-2015).

Flagship target


Expected Impact

Prevention of the appea-rance and progression of chronic illnesses. For example, in the De_Plan a reduction in the risk of developing Type 2 Diabe-tes in 58% of the popula-tion, or the reduction of tobacco demand by introducing habit kicking treatment

To construct a common framework of Health Prevention and Promotion combining with the strategic lines on the principal risk factors with innovative bottom-up pilot projects, such as, for example, the De_Plan project: Prevention of the progression of Type 2 diabetes in high risk subjects between 45 and 70 years of age (approx 200,000 persons)

De�nition of strategic lines

Launch of Pilot projects in selected centres

Extension of successful pilot projects to all the Primary Care centres in the Basque Country

Updating of the strategic lines and selection of pilot projects to be started up

May – June 2010 June 2010 – December 2012

2 Prevention and Promotion Interventions against the principal risk factors

Table 15: Strategic Project of Prevention and Promotion



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STRATEGIC PROJECT 3.Self-care and patient training Scientific evidence demonstrates that patients who self-manage their illness, having received support in order to be able to do so, obtain better results controlling their illness than those patients who do not carry out self-care. to achieve this goal a wide range of structured education interventions can be used.

in the Basque country various measures will be applied, both in face-to-face and remote teaching, individual and group, by health professionals or by “active patients”, with specific training to improve patients’ levels of self-control, or those of the carers when necessary.

in particular, the Active Patient Model – Paziente Bizia following the methodology of the university of Stanford, will begin at the end of 2010, following a pilot programme at the end of 2010, after the formation of a group of health professionals and active patients who can begin to train other patients.

Flagship Objective


Expected Impact

• Experiences in the main chronic illnesses

• Greater adherence

• Appropriate use of health resources

“Introduction of the “Chronic disease Self-Management Program” Univer-sity of Stanford”. Actions:• Enabling “Master Trainers” for the training of “leaders”.• Enrolling patients and initiation of courses to these patients (6

sessions for a total of 15 hours per course). • Training leaders (from amongst trained patients and health workers)

to enable them to give courses to other patients.

Master Training for 15 trainers for patients

Selection and training of Patients to become Trainers

Pilot project in the Areas of Ekialde, Araba and Eskerraldea

Extension to other areas and illnesses

Identi�cation and piloting of other self-care and education initiatives for the patient

June- July 2010 September 2010 October 2010 -June 2012

July 2012 onwards

3 Self-Care and education for the patient: Active Patient Pilot Project – Paziente Bizia

Table 16: Strategic Self-Care and Education Project for the patient


istockphoto - getty images


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STRATEGIC PROJECT 4. The setting up, by the Associations of Chronic Patients, of a Network of Activated and Connected Patients using Web 2.0 technologies Achieving a network of activated and connected patients, accountable for their own health and taking responsibility for their own care when they suffer from a chronic illness, capable of receiving and offering support to other people who find themselves in the same situation, requires work in other areas outside the health service as well. the Patients Associations cover these other areas, aside from health, in which the chronic patient is involved, including personal, family and social.

n order to get across to these patients the principles of co-responsibility and self-empowerment which we consider to be of priority importance in the relationship with the health sector, and, furthermore, to extend, this idea to those who are continuously dealing with the patients (families, carers, support professionals), one of the basic strategies is that of supporting and strengthening the patients associations. the strategic project which is presented below will help them to take advantage of new technologies (Web 2.0) to enable easier and more active communication between members, encouraging the socialization of existing knowledge- not only about the illness, but also about how to lead a more active and better quality life – enabling this knowledge to evolve and spread to all members openly, without limitations of time or distance.

to this end, an offer of financial and technical aid has been made to the main chronic patients and carers associations in our region, to encourage them to develop a strategy of communication and interaction for the communication and mutual support as well as knowledge dissemination using Web 2.0 technology which will favour the set up a social network between members.

this initiative will be further enhanced by the setting up of a common platform for all the associations, which will enable the breaking down of barriers between each illness, making it easier to set up social support networks for people who are affected by similar circumstances despite suffering from different pathologies. Synergies will also be created between associations and the path will be laid open for collaborative projects in the future.

the platform will enable the patient to become active, even with regard to suggestions and feedback regarding any innovative experiences which are helpful for his or her needs, promoting a different path along which to proceed for the various agents involved (the Patients Associations themselves, the Social and education Services, and the health System). these alternatives will be considered as potential pilot projects by the Department of health and consumer Affairs, with the aim of assessing their results in the future. All involved parties will become potentially active agents in the innovation and transformation of our health system and in the relationship between other public and private areas.

eventually, this common platform of networked patients will be able to link up with other networks which have been set up in other strategic projects such as oSAreAn, the Active Patient and certain Prevention initiatives such as De_PlAn. firstly, the patient associations can seek support from oSAreAn, making full use of the training services and materials offered by this platform. Secondly, this common platform will enable the patient groups which have been set up in the expert Patient or De_PlAn projects and which wish to extend their connection beyond the health system to do so via the new technologies.



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Flagship Objective

Calendar – Principal Milestones25Marzo

Expected Impact

The creation of virtual communities of patients based on the 5-10 main associations of chronic patients in the Basque Country

Support chronic patient associations in the adoption and use of new communication technologies (Web 2.0) in order to improve access to information and to promote interaction and mutual support between members

Announcement and award of aids

Development of projects by the chronic patients associations

June 2010-Sep 2010 2010 – 2011

4 Support to the associations of chronic patients

Table 17: Strategic Project for adopting new technologies by the chronic patients associations



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STRATEGIC PROJECT 5.Unifi ed Medical Record:Osabide Globalthe project of the Shared Medical record was put into action in the Basque health Service (osakisetza) 12 years ago by way of two strategic projects: osabide-AP, aimed at Primary care and e-osabide for hospitals, with the objective of eliminating all the existing barriers between the organization of services, centres and care levels at that time.

As far as the support systems for medical procedures is concerned, the experience of shared medical records in the Basque health Service (osakidetza) goes back almost fi fteen years, becoming a basic tool for doctors and nurses. the degree of use varies depending on the care area: in Primary care or emergencies it is totally integrated, in other areas it is more limited. nevertheless, in general terms, it can be said that the balance is a very positive one.

once the fi nal phase of the process of systems renovation was achieved, both for Primary hospital care, in 2009 the decision was taken to move towards a new generation of medical record systems.

this new generation is seen as a leap in quality over from the existing systems, and basically follow the following lines of work:

• The elimination of all existing organizational barriers, so that all professionals involved in care share all the existing information on the patient supplied by communication mechanisms in real time.

• The authorization of mechanisms of patient interaction which go beyond face-to-face consultations, (telephone consultation, email, video-conference by web-cam, etc.).


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• The setting up of proactive information systems which manage the information according to its relevance, and bring to bear elements of “intelligence” (e.g. medical alerts, warnings).

currently, the system is in the initial pilot stages in three care areas: outpatients, conventional hospitalization and home hospitalization at three hospitals in the network. the plan aims to tackle progressively the different areas of care until covering all areas by the end of 2011. for each one of the areas, as with the first two, an initial pilot stage is established with a limited number of professionals. During this stage appropriate adjustments will be carried out, on the basis of its practical utilization. once validated the oSABiDe gloBAl Application will be extended to the rest of the professionals within the Basque health Service (osakidetza).

the plan for 2010 is centred in its introduction into the hospitals: hospitalization at home and outpatients (already started in April), hospitalization (begun in July) and emergencies (foreseen for the end of 2010).

Flagship Objective


Expected impact

Universal introduction of the uni�ed medical record by the end of 2011, o�ering an integral treatment to the patient, increasing medical precision and reducing the time spent by doctors to clearing up questions related to the patient’s medical record

To create and deploy Osabide Global, a sole solution for medical records for all levels of care throughout all the network of centres which will enable professionals access patient data in the Basque Country and modify it when necessary

Design of the data �elds to be included and developed

Extension to all centres and for all health professionals

Piloting• Home hospital • Outpatients

• Hospitalitation• Emergencies

Jan – June 2010

Feb – Dec 2010

Jan - Sep 2011

5 Uni�ed Medical Record: Osabide Global

Table 18: Strategic Project of the Unified Electronic Medical Record



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Flagship Objective


Expected impact

Universal introduction of the uni�ed medical record by the end of 2011, o�ering an integral treatment to the patient, increasing medical precision and reducing the time spent by doctors to clearing up questions related to the patient’s medical record

To create and deploy Osabide Global, a sole solution for medical records for all levels of care throughout all the network of centres which will enable professionals access patient data in the Basque Country and modify it when necessary

Design of the data �elds to be included and developed

Extension to all centres and for all health professionals

Piloting• Home hospital • Outpatients

• Hospitalitation• Emergencies

Jan – June 2010

Feb – Dec 2010

Jan - Sep 2011

5 Uni�ed Medical Record: Osabide Global

STRATEGIC PROJECT 6. Integrated medical care this project is experimenting with different approaches to clinical integration, especially between Primary and Specialized Care. this experimentation will enable a gradual advance in a way which is compatible with the specific reality of the service organizations as well as an extension of the experiences which have proven to be more successful.

it is not an attempt to define a unique model of integrated clinical working practices to be applied to all regions and centres, as, in general, the needs and possibilities of integration will be different in each case, but it does require a determined step, on all parts, to share new practices and whenever the case is presented, to universalize models which have proven to be particularly successful in certain areas or procedures.

By its own nature, this process of clinical integration will be relatively slow, and for it to be successful it has to be set up by local healht care personnel and management staff, supported by senior management to maintain momentum and to add fine-tuning. Moreover, posterior efforts in this line have to take into account other levels of care, principally the centres for mental health.

Flagship Objective


Expected impact

One third of the organizations for 2013, with integrated procedures which will allow continuous interventions which reduce the number of duplicated structures and “referrals” between care provision sectors

To explore through the experiences of the pilot projects new ways of working and organizing of the health care suppliers, integrating primary care and specialized care

Integration in psychiatric care in Bizkaia

Extension of the successful models

Organizing and procedural integration in the Bidasoa hospital and its health centresProcedural Integration in the Mendebaldea local area and between Galdalkao Hospital and the Interior area

January – June 2010 June 2010- January 2011 2011 – 2012

6 Integrated medical care

Table 19: Strategic Project of integrated medical care



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Flagship Objective


Expected impact

Introduction of the model in mid-term stay hospitals and the set up of a new chronic hospital in Alava

De�nition of a model of care for chronic patients, consolidating an intermediate level of care between specialized and primary care for the speci�c care of these patients

De�ning the model Introduction of the model, especially in mid-term stay hospitals, but with the possible consequences in local hospitals and acute hospitals

January – May 2010 June 2010 – December 2012

7 Development of sub-acute hospitals

Table 20: Strategic Project for the development of sub-acute hospitals


STRATEGIC PROJECT 7. Developing sub-acute hospitals the reality of chronicity makes it increasingly necessary to establish an intermediate level of care with a lower level of technology and with a lower level of care than in a conventional hospital for acute patients, but at the same time with an integrated care capacity more developed than that of traditional Primary care centres.

current medium-term stay hospitals are the perfect place for this development. therefore, a new model of sub-acute hospitals is being set up and developed which can treat the reagudization and the rehabilitation of chronic patients in a way which is more focussed on the patients’ needs

and more efficient for the System. it is also the kind of hospital which is connected to the community and which can act as a centre of coordination between hospitalization and the home and which can coordinate cases and integrate care levels.


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STRATEGIC PROJECT 8. Definition and implementation of advanced nursing competences the challenge of better management of chronic conditions is an important opportunity for nursing, a profesion which is our setting ahs been looking for new references and functions. At the same time new regulatory changes in the training of nursing will reinforce their relative position as health care profesionals.

With the aim of defining and implementing nursing roles which are better adapted to the needs of chronic patients, a multi-disciplinary work group has been set up by the Department of health and consumer Affairs and the Basque health Service (osakidetza).

throughout 2010 and within the framework of action of this work group, the aim is to draw up a proposal for the development of new advanced nursing competences focussed on chronic care, to reflect on the possible framework of responsibilities, and to identify the related training needs (necessary steps previous to specific pilot projects on case management models in 2011).

Flagship Objective


Expected impact

To train 300 nurses in the Basque Country in new roles up until 2013, seeking to obtain an integral level of care for the needs of complex patients

To de�ne and develop advanced nursing competences in Osakidetza in relation to dealing with chronic patients, in particular complex chronic patients. Leverage in successful cases in other health systems (national and international)

Benchmarking and role selection for analysis

De�ning model and budget scenarios

Training and piloting (centres to be decided)

Extension to all centres

Methodology based in working groups with the agents who are involved

May- June 2010 June – Oct 2010 October 2010-2012 From 2012 onwards

8 Advanced nursing competences

Table 21: Strategic Project of advanced nursing competences



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STRATEGIC PROJECT 9. Social and Health Services Collaborationthroughout this document we have seen a series of strategies which lead to a change in the relationship with our chronic patients, which will develop from a purely biomedical vision to a holistic vision which has to take into account diagnoses, the social function and situation of the patient in order to establish an individualised plan of care by multi-disciplinary teams.

this project puts into practice the integral assessment of the patients and encompasses all the elements of the vision of this care strategy

to chronicity including the socio-health aspects for the Basque population, not only through the incorporation of new resources, but also by means of the reorganization and coordination of the Health System and the Social Services, offering formulas which integrate a complete package of services for the users.

the social-health service is framed within the objective of providing social-health care, as stated in the Social Service Act 12/2008, 5th December, and defined as “all care offered to people who, due to serious health problems or functional limitations and /or being at risk of social exclusion, need coordinated and stable simultaneous social and health care”. Among groups which likely to fall into this category are: elderly people who are dependant on others, disabled people, people with mental health problems (in particular those with a chronic serious illness and people with drug dependence problems), people with chronic somatic illnesses and/or invalids, people convalescing from illnesses who, despite being discharged from hospital, do not yet have sufficient autonomy for self-care, people with terminal illnesses, and other groups at risk of exclusion.

the success of the project requires the involvement of all the providers of social health services and therefore, it is currently undergoing a consensus procedure with the institutions at the three levels of social service action: the Basque government, the county councils and the town halls. What is being sought is not just coordination, but a synergy resulting from the joint action of all the involved parties.

in short, the three major strategic objectives which are included in the project are as follows:

1. To develop the social health services, enhancing socio-health coordination at Primary care level through interdisciplinary teams, as a guarantee of integrated care throughout the period of care, considering the home as the principal provider of care, as well as promoting and standardizing the development of socio-health resources in the three Provinces.

2. To improve the coordination of systems and structures at socio-health level, promoting the existence of a common legal framework which specifies the catalogues of social and health care, as well as drawing up a new model for the financing agreement for socio-health services.

3. To enhance system management to bring about an improvement in the levels of care, by means of training and increasing the awareness of everyone involved in socio-health coordination, as well as the implementation of a shared information system.


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the putting into action of these strategic objectives will reach fruition with the development of suitable operative Plan for each Province.

Flagship Objective


Expected impact

Multi-disciplinary PC teams with the home as the principal provider of care in 2010:4 municipalities with integrated working, 1 hospital with an admission plan with dependence prevention, 1 unit of orthogeriatrics

To develop a framework of social and health services collabora-tion with all the social service actors (Ministry, Provincial Councils, Town Hall). It will develop master guidelines to provide an integral response to chronic patients which have simultaneous need for social and health care

Jan – March 2010 April – May 2010 June 2010-2012

9 Socio-Health Collaboration

Definition of the socio-health framework (health vision)

Uniting the socio-health framework with the social protagonists

Joint work on specific lines and introduction of agreements

Table 22: Strategic Socio-Health Collaboration Project



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Flagship Objective


Expected impact

Fully introducing a system of provisional financial allocation adjusted for risk,with prioritization and focus of the health expenditure, aiming it towards criteria of efficiency and effectiveness

To adapt the mechanisms of financing health suppliers (Contracting Programme and Agreements), moving progressively from an activity strategy to an adjusted population and health results strategy, aimed at providing care which fulfils the objectives of the chronic illness strategy

June 2009 - April 2010

June 2011 -Feb 2012

June 2012 -Feb 2013

June 2010 -Feb 2011

10 Financing and Contracting

Contracting 2010 currently in effect and follow up phase)

Contracting 2011 Contracting 2012 Contracting 2013

Table 23: Strategic Project of Financing and Contracting


STRATEGIC PROJECT 10. Financing and Contracting the beginning of the 21st government has heralded a change in the leadership of the Department of health and consumer Affairs and the arrival of a different way of understanding the Basque health System. this new vision will mean the promotion of a strategy which requires a strengthnin in the commissioning .

Similarly, changes will be made in clinical management level in order to align with the new approaches. in the Basque region commissioning is carried our by the provincial health authority level; the function is not decentralised to provider units.

this set of circumstances makes it an ideal moment to reflect on the usefulness of the Commissioning process, its structure and its content. this reinforcement of the commissioning process is being designed for all health care activity but for the first time specific signals are being sent to providers the contract in relation to chronic disease programmes and in relation to the need to identify approaches to integrated care .

in this sense, changes have been made in the renewal of the contract of health services which include commitments, actions, and standards in chronic illness procedures which involve both primary and specialized services, incorporating commitments to home care at both levels and also in the areas of patient safety, palliative care and social and health services integration.


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Flagship Objective


Expected impact

Fully introducing a system of provisional financial allocation adjusted for risk,with prioritization and focus of the health expenditure, aiming it towards criteria of efficiency and effectiveness

To adapt the mechanisms of financing health suppliers (Contracting Programme and Agreements), moving progressively from an activity strategy to an adjusted population and health results strategy, aimed at providing care which fulfils the objectives of the chronic illness strategy

June 2009 - April 2010

June 2011 -Feb 2012

June 2012 -Feb 2013

June 2010 -Feb 2011

10 Financing and Contracting

Contracting 2010 currently in effect and follow up phase)

Contracting 2011 Contracting 2012 Contracting 2013

in this line, in 2010 changes have already been made to the current Programme contract Models in order to adjust them to the new plans and strategic priorities. these changes have been structured around the General Contracting Plan for Health Services and their adaptation for each province according to the three Provincial Purchasing Plans. furthermore, a particularly important role has been assigned to the development of actions and measures within the framework of chronic patient care. in addition, the integration and care continuity projects and their financing have been given priority, as well as projects aimed at improving care quality through the use of technologies, the definition of new integration procedures, etc. throughout this process those projects have been highlighted and prioritized which, as well as focussing on the aforementioned priorities, will involve the defining of shared objectives by more than one organization.

A mixed coordination committee made up of all the agents from the different levels of organization involved in health care contracting has participated and will continue to participate both in the definition of these objectives and in their assessment.


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STRATEGIC PROJECT 11. OSAREAN: Multi-Channel Service Centre the Department of health and consumer Affairs of the Basque government, through the Basque health Service (osakidetza), is supporting the setting up of a Multi-channel health Service centre (MhSc) which will increase the number of ways in which the public can interact with the health system.

this project is critical from the point of view of chronic care as it will serve as a tool with which to maintain the level of low intensity constant contact which is required by chronic patients, in contrast to the sporadic high intensity contact

which acute patients receive from traditional face-to-face care.

the aim of the project is to use all the available channels of interaction (Web, telephone, SMS, Digitial television,…) between the citizen and the health system in order to facilitate the care procedures, porviding them with greater agility and more decision making capacity, in such a way that, interactions between the public and the health system interfere less with their personal life and work. furthermore, it will add value to the medical work, offloading administrative procedures, monitoring activities and routine check-ups, with the aim of focussing on higher value activities. finally, it will promote the involvement of the citizen with their own health and the patient with their illness using channels complementary to face-to-face, as a key strategy to improving the health results throughout the health system, converting citizens into agents of the health system.

the final objective of the MhSc is to help the Basque health System to fulfil its objectives and to contribute actively in the transformation of the current Health System affording the Basque society with remote multi-channel mechanisms of health care provision through the application of it and telemedicine. it will bring the public services closer to the citizens making use of new technologies, improving efficiency in the use of resources, and by introducing demand management mechanisms which will contribute at the same time to an improvement in the quality of services provided.

As far as the principal services to be provided are concerned, the MhSc will enable administrative procedures to be carried out (primary care appointment management, reminder and/or confirmation of appointments, medical certificate reports, tiS (personal health card management,…) and will make general health service information available to the users (range of services, health centre directory, night clinics and duty pharmacies). Moreover, it will foster health promotion, information and education, through the Patients Forums for the promotion of healthy lifestyles and vaccination reminders and information regarding Public health programmes. chronic patients will also receive training in the management of their illness, and remote monitoring will be promoted in order to carry out precautionary action during the phases of medical destabilization, coordination between health services will be fostered (e.g. with emergency services, access to medical data and guides and online corporative protocols). there will also be a telemedicine home care service (remote assessment systems and telemetric monitoring) for domiciliary chronic patients, multipathology patients and those with advanced or unstable pathologies. finally, the MhSc will provide Medical Advice and will enable the citizen to access information regarding his or her health (personal health file).

the linguistic teleinterpretation Service has been in operation throughout the Basque health Service network (osakidetza) since february 2010, and in the near future a


53

contact centre will be set up to attend the public (pilot project for 50,000 citizens in Bilbao). As far as telemonitoring is concerned, there are a series of pilot projects taking place both in Primary and Specialized care:

• Primary Care: Diabetes in Alava and uribe costa, cardiac insufficiency and/or ePoc in Bilbao, and ePoc the interior region.

• Specialized Care: Diabetes in hospital Donostia, remote monitoring of cardiac stimulation devices in txagorritxu hospital and chronic obstructive Pulmonary disease in galdakao hospital.

• other projects in the study phase with possible actions in the near future are:

• remote monitoring of cardiac stimulation devices in hospital Donostia.

• communication of tAo results and prescription support using Web access and SMS.

• introduction of new systems of non face-to-face interaction in mental health services in gipuzkoa.

Flagship Objective


Expected impact

Deployment in the Basque Country of all the services of the Multi-channel Service Centre by the middle of 2013, offering to the citizen greater ease of interaction with the system and an improvement of the efficiency in the provision of services and allocation of resources

To develop a technological and organizing platform which permits multi-channel interaction with all the citizens of the Basque Coun-try with the health system, enabling procedures, simplifying the life of the citizens and giving prestige to the work of the health professionals

March- Nov 2010 March- Nov 2011 Nov- March 2013Nov- March 2011

11 OSAREAN: Multi-Channel Service Centre

Development of the platform and basic deployment to 400,000 inhabitants

Piloting of tele-monitoring

Incorporation of new services and basic deployment to 1,000,000 inhabitants

Deployment and extension of new services – basis deployment 100

Progressive deployment of all the planned services

Table 24: Strategic Project of Multi-Channel Service Centre



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STRATEGIC PROJECT 12. Developing e-pharmacy and e-prescription the correct use of medication and its correct administration forms an integral part of the good management of chronic illnesses. this requires improving medication management, providing information and education to the user, supporting better prescribing in Primary and hospital care, as well as the process of dispensing and administration of medicines.

the e-prescription involves the integration of the procedures of pharmaceutical supply (prescription, permit, dispensing and invoicing) based on information technologies. it enables a

change from the concept of the pharmacist’s prescription to the establishment of integrated pharmacotherapeutic plans, particularly relevant from the point of view of chronic illnesses due to the existence of multimorbidity, complexity and long duration of the associated pharmacological treatments.

the introduction of the e-prescription is expected to have a significant effect on the population affected by chronicity to the extent that the control, the safety and the quality of the pharmacological treatment will increase. it is also expected to provide a quality prescription, to broaden the level of pharmaceutical care and to reduce administrative paperwork. furthermore, it can serve to boost the role of the citizen/patient with regard to their responsibility and autonomy and even contribute to the development of multi-disciplinary, coordinated and integrated care provision. it can also support patient self-management and education.

the e-prescription is, therefore, a powerful tool which, together with others, will contribute to the achievement of the following objectives: foster the role of the citizen at the core of the health System, promote the integration and continuity of care provision, improve patient safety, boost efficiency in the use of medications, improve care for chronic patients and develop a risk stratification.

the introduction of the e-prescription is currently being extended to all the Basque community.

Flagship Objective


Expected impact

E�ective introduction of the e-prescription system throughout the Basque Country by 2013, increa-sing the safe and e�cient use of medici-nes, eliminating “admi-nistrative” visits to the centres and saving time and trips for citizens

To introduce the system of e-prescriptionCreating a single electronic pharmacotherapeutic record of the patient encompassing all care levels, making the necessary information available to each of the di�erent protagonists involved and reaching integration of the prescription-dispensation

June 2010 – Dec 2011 2013 (approx) 2012 (approx)

12 Strategic Project of e-prescription

Development of the system and extension to Primary Care. Initiate the deployment in Specialized Care

Extension to all the Specialized Care centres, socio-health, residential and nursing centres

Extension to associated centres, other doctors and interoperability and dispensation in hospitals

Table 25: Proyecto Estratégico de receta electrónica




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STRATEGIC PROJECT 13. Setting up the Centre of Research for Chronicity All the aforementioned strategic projects will generate for the Basque health system a wide range of experiences for improving the treatment of chronicity and the sustainability of the health system: experiences which will be logically assessed and researched in order to evaluate and demonstrate their efficiency and their capacity to be scaled up throughout the health system.

this logical analysis and assessment applied to an important number of projects accompanied by a strategic change in the system of care for the chronically ill will enable the Basque health service to become a point of international reference for knowledge generation and scientific evidence. this, in turn, will attract top class researchers capable of relating the experience accumulated in the Basque country to that of other countries, thereby generating a network of improved scientific evidence at international level concerning the treatment and care for chronicity.

the setting up of a Centre of International Excellence in Chronicity will enable innovative practices to be identified at international level and the structured generation of scientific evidence regarding new forms of treatment for chronic illnesses by means of an international network of agents which will make it easier to draw more generalized conclusions from this research as it will be carried out in different contexts.

At the same time, it will be possible to benefit from the “pull effect” which this research capacity will have on various activity sectors related to the Biohealth and Ageing cluster, both from the point of view of generating new products related to chronic care in different environments, and with innovative socio-health services.

this initiative will facilitate access to state of the art knowledge and research methodologies, as well as national and international sources of funding, strengthening the establishment of an innovative health system, capable of incorporating research into actions for resolving challenges over time, and prepared to generate the necessary scientific evidence to implement these innovations within the system of publicly financed care provision.


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Flagship Objective


Expected impact

To be a an international point of reference for knowledge about chronic illnesses, generating evidence that will o�er support to the di�erent initiatives and projects related to them

The establish a research centre to identify, adapt, pilot, and introduce the best practices to deal with the challenge of chronicity, generating “glocal” knowledge for innovation in organization and management and to improve the health systems

April – July 2010 June 2012 - February 2013September - October 2010

13 Research Centre for Chronicity

Design and functions proposal for the Research Centre

Feedback process from stakeholders

Set up of the Research centre

Table 26: Strategic Project of the Chronicity Research Centre



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Flagship Objective


Expected impact

To be a an international point of reference for knowledge about chronic illnesses, generating evidence that will o�er support to the di�erent initiatives and projects related to them

The establish a research centre to identify, adapt, pilot, and introduce the best practices to deal with the challenge of chronicity, generating “glocal” knowledge for innovation in organization and management and to improve the health systems

April – July 2010 June 2012 - February 2013September - October 2010

13 Research Centre for Chronicity

Design and functions proposal for the Research Centre

Feedback process from stakeholders

Set up of the Research centre

STRATEGIC PROJECT 14. Innovation on the part of the medical profession Several of the aforementioned projects are strategies conceived from top to bottom as lines of work which are necessarily uniform and standardized for all the Basque country. (e.g. medical records).

however, other changes invite research-action which is led by doctors, nurses and managers at local level. in many senses, the necessary change is both a medical and an organizational challenge as well as one which affects leadership and the management model. the new paradigm which is presented requires a change in the organization with the consent and leadership of the professionals involved.

in particular, this line of strategic work will encourage local experimentation, creating conditions for the base to be able to look for “their” best solutions. A way of activating local initiative is to provide resources and facilities so that local teams can start pilot trials in system management. the managers, the health professionals and the end users are the parties which should receive support to have the organizing capacity sufficient to improve their areas of involvement.

these conditions are being achieved through the various mechanisms which will be providing bigger and better resources over time.

the internal processes of research financing have been activated, both commissioned and non-commissioned, in order to promote local initiative in research actions. the philosophy is to promote innovation in health care organization to the same extent as biomedical innovation, fostering experimentation with a research perspective. this is the reason why, since the year 2010 we have defined a new research modality named with the dual scientific and active term action-research. this is a pioneering modality in Spain and the aim is to establish the importance that this strategic change is affording the promotion of innovative attitudes at the heart of clinical teams. the projects presented to the 2010 study review will be assessed by a specially selected committee which will seek to support the base initiatives, whenever these are aligned with the strategic objectives and have the appropriate experimental organization and design.

for this level of rigorous research to be compatible with a focus on action, a methodological support and research-Action project integration team has already been set up, which will support the different teams of medical professionals so that their results can be assessed, shared and systematized. this team will be made up of osakidetza personnel, with a stipulated dedication to this function, forming a functional action-resaerch unit. to ensure a level of excellence and proficiency in research methodology, both osteba and o+Berri, will make sure the team is continually updated in material, promoting its increase in capabilities and competence.

thus, by means of the projects which the Service organizations are committed to carry out in the quality Annexes of the commissioning Programme, the initiatives of the clinical personnel are being aligned with those of the service organizations, having an impact on the financial resources which these could end up receiving. this route is particularly useful to identify the projects in healht care innovation which are of most interest to the different service organizations and which are likely to be rewarded with successive research funding in research action.


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in addition, a support procedure has been designed for developing, assessing and extending to other local areas those projects which prove to be cost-effective in the Basque system. this process will be carried out in pilot form in 2011 with the projects which come to an end during that year and will be made definitively official from 2012.

Flagship Objective


Expected Impact

Generation of 15-25 innovation projects a year and the extension of those which produce health results and sustainability (it is hoped that 90% will produce results)

To design the process, the tools and the leaders with the aim of facilitating and promoting emerging innovation by means of pilot “bottom up”projects, and to ensure its sustainability and extension throughout the Basque Country, when the desired results are reached

May 2010 -June 2010 2010 – 2011

14 Innovation from the medical professions

Innovation Pilot projects 2010:Learning

Carrying out and monitoring the official process - 2011

Detailed defini-tion of the process and tools

Table 27:Strategic Project for innovation on the part of medical professionals



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Achieving change: An Implementation strategy


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acc ep T i n g co M pl e X i T yhow do we advance to a more proactive health system? how do we educate patients to be active participants in the management of their illness? how do we improve clinical integration between primary and hospital care? how can we make a qualitative leap in the use of technologies and Web 2.0 applications in benefit of the patients?

All the aforementioned strategic projects have many aspects in common, but one in particular: their complexity. the fact is that many of the transformative projects included in this strategic framework require a number of complex interventions in numerous areas of activity; there is no “magic wand” to carry this out. it is necessary to work through many levers of change; these numerous levers are represented by the 14 strategic projects described above.

changing from the current system to one which is capable of providing excellent care to chronic patients cannot be achieved without a progressive and integral transformation of the system of care provision. this is one of the clear lessons from implementation practice in this and in other areas.

the temptation of the corporate leaders may be to want to accelerate the pace of these transformations by means of direct and regulatory structural changes. however, this Strategy on chronic care is riddled with complex changes and as a consequence its projects cannot be merely imposed in an interventionist fashion: to achieve our goal it is necessary to follow a path which is less interventionist and more emergent. in planning terms, to identify for our context a successful balance of a traditional planning approach with a more emergent end learning approach.

A great number of the Strategic Projects in this document require new relationships and collaborations between different actors in the health system, actors which up to now have been living in a silo structure.

To p- d o W n a n d b oT To M - u p

there is always tension between an excessively interventionist or top management approach and local decision making capacity. in the past, in the Basque country there has been too much of the former and not enough of the latter. in the case of this Strategy the aim is to find a better balance in decision making as it is our opinion that local managers and professionals will very often find more innovative solutions than central planners.

Many directors may think it ingenuous not to exercise a control of even greater imposition during these times of economic crisis with the objective of rapidly imposing the changes described in this text as, among other things, these changes open new avenues to enhance the sustainability of the health system and hence their urgency. however, all the scientific and management evidence indicates that the naïve policy would be just the contrary: trying to impose this system transformation.

in the implementation of the Strategy for the Management of chronicity in the Basque country a new balance is sought developing a more distributed style of leadership: neither a purely interventionist focus “top down” and more development focussed “bottom up” style would appear to be insufficient to act alone as motors of change:

• on the one hand, an entirely interventionist focus “top down” often encounters difficulties to encourage clinical leadership, something essential for most of the changes explained above. this may make the adaptation of the interventions to the local reality impossible and, generally speaking, leads to failure in their implementation, either because the interventions are not taken onboard in the day to day clinical


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Cleardirection

Extensionmechanisms

Success is acquired throughthe combination of both focuses

Not acceptable for Doctors

No encouragement for localleadership and no adaptationto local conditions

Interventionism is not enough Development focus is not enough

Does not achieve scale,nor supports nor expandssuccessful interventions

Does not create a commondirection with which to galvanizeall the energy

Leadershipand energy

for innovation,implementationand extension

Status Quo

Need to changeis perceived

New strategy New vision

Top managementcreate a Plan

The plan is presentedand commitment

is sought

Implemented bymiddle management

New way ofintegrated workingin the health sector

Table 28: The need to combine strategic direction with medical and managerial commitment

Innovation and change must combine clear strategic direction with the commitment of the first line of doctors and managers


procedures or because they are not suitable to the specific needs of the patients and health professionals at a local level.

• on the other hand, although a purely developmental approach, via a “bottom up” action, one may be able to bring about successful experiences driven by some health care professionals at a particular health centre, there will be a lack of support, tools, or formal mechanisms to extend the experience to a wider area; thereby generating “islands of excellence” which are never scaled up and finally become obsolete or may disappear along with its creator. furthermore, even in the cases in which some scaling up is achieved, the focus soon stumbles due to the absence of a strategic direction, something which tends to make initiatives incompatible or redundant.

for these reasons, to implement the Basque Strategy on chronic care, the tactical decision taken has been to systematically combine both focuses: adopting a clear strategic direction, which is filtered simultaneously through an emergent process originating from the front line of health professionals and managers as they bring about the changes they seek.

this requires a living strategy that evolves and emerges, so that the focus of the implementation is also a living process which will progress as the lessons learned from changes (in the Basque country and elsewhere) are assimilated.

Top-down focus – A Clear Strategic Direction

the proposed change requires clear directions from top management and the setting up of a playing field suitable for it to take place, one which provides support and the tools for its undertaking and the objective and standardized measurement for its progress.

to this end the first components are a vision and a list of common aspirations. it is necessary to make absolutely clear what the vision is and what goal is aspired to through the change;


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a vision and an aspiration which evolve and gather the knowledge from the organization, but at the same time are clearly communicated and shared by the executive management level, so that there is no doubt about the direction being taken and no opportunity is lost to underline its essence.

in the chronic Patients Strategy the vision consists in transforming the system so as to be able to provide an excellent level of care for chronic patients as well as for acute patients; as an aspiration, a common target has been set in terms of the number of patients in each stage of their illness who will receive the new type of care which will adapt to his or her needs as chronic patients. this aspiration makes the change tangible, making it a real transformation for health professionals, patients, managers and catalyses the transformation as specific interventions are adapted to the results of the changes inspired by health professionals and the resulting scientific evidence.

furthermore, certain basic rules of play have to be laid out and shared between managers and health professionals, these have to be the same for everyone, and be oriented to the vision defined above and adhered to without exception. in this case, the ground rules consist in results-based financing which promotes the use of the most efficient and best adapted resources for each case, and the choice of interventions according to the criteria of the scientific evidence.

At the same time, it is essential to provide support from the top, with the necessary technological, technical and organizational tools for the administrators and health workers for them to make the vision a reality. in the chronic Patients Strategy the tools are technology (unified Medical record, Multi-channel Service centre, e-prescription), methodological support for innovations at the grass-root level ( providers ), and a population based approach understandable by health care professionals and managers ( population stratification to enable “targeting” of interventions).

Casemanagement

Caremanagement

Support forself-management

Prevention

Promotion

Aspiration 2013Nº of patients with new care

6,000

35,000

35,000

40,000

Table 29: Aspirations of the Chronic Illness StrategyThe vision can be transformed into tangible aspirations for the period up until 2013



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finally, the last task to be carried out by top management is that of monitoring progress: a transparent tracking in relation to the shared aspirations and indicators, and monitoring which will establish unequivocally if the targets are being achieved or not at each of the levels, with the aim of supporting and expanding measures which work and abandoning those which do not.

Bottom-up focus – The change from local health professionals and managers

the agent change is not the corporate leadership, though it is essential that these create the conditions for the change to take place at the operational level. eventually, the objective of this Strategy is to set up more innovative health systems at a local level, and at an operational level (micro-systems). it is at this level in which the real agents of change can be found, and in which the interactions take place between the patient and the health professionals: the level at which the service is provided.

therefore the bottom-up focus, complementary to the top-down focus, has to give autonomy and space to the local health professionals and managers so that they can improve their working practices and the level of service they provide to chronic patients. this requires fostering change and giving the necessary support to those who try to implement it.

the first part of the bottom-up focus implies giving freedom and “room to manoeuvre” to the health professionals and managers so that they can reach the objectives in the most appropriate way according to their respective service organizations and circumstances.

to achieve this, it is necessary that the health professionals and managers are given total support, fostering continuous improvement in their work; giving them responsibility to change the way things are done and giving them the time to analyze and experiment, which involves giving access to management information so that they can measure and assess their own activity and reach conclusions whether it is effective or not.

But this support cannot be given successfully without providing both health professionals and managers with the training, the capacity and the responsibility of operating in this kind of environment. this distributed leadership requires being able to support people who manage with a different kind of mentality to that which is usually found in the leadership hierarchy. to this end training is being offered to 150 managers and directors of the service organizations, training which will provide them with the tools and a clear mandate to work in this fashion.

finally, the most important piece of the “bottom-up” model, which converts the aforementioned strategies into reality, is the process of innovation emerging from health professionals, which allows the energy for improvement and innovation generated by the managers and doctors to be channelled and focused. there are presently more than 30 bottom-up demonstrator sites activated seeking with this approach.

Creating the conditions to innovate from bottom-up:

Specifically the actions which are being carried to achieve bottom-up advances are the following:

• to promote research in health services to bring it to the level of bioscience research.

• to create an organization whose function is to support this emerging process of research/innovation in health services (fundación o Berri).

• to offer specific training to 150 managers of service organizations in order to give them the tools and the clear mandate to operate in the desired fashion. Distributed leadership, clearly different to the classic hierarchal leadership, requires training for managers and health professionals so they can acquire new capabilities with which to develop their new responsibilities in an environment of this kind. there are several lines of training opened for these groups.


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• to launch ambitious research grants from the Department of health and the commissioning process for 2010 with the aim of offering incentives for local experimentation in health service innovation. the ideas which are selected will receive methodological support (e.g. research methodology, system processes), procedural (e.g. follow-up, breaking barriers) and financial support so as to fund them. the research methodology will be action-research, to a sufficient scale to be able to underwrite their effectiveness.

• from these trials a connection will be made, both face-to-face and remotely, with the various innovative micro-systems with a view to disseminating learning as quickly possible.

• to develop a rigorous assessment of the innovative micro-systems and to select those which demonstrate effectiveness in the context of the Basque country in order to be able to extend them throughout the system. it is important to note that the innovative micro-systems are emedded within a wider health system. they are not isolated islands. their lessons will be disseminated to the rest of the system in an organized fashion in order to improve the entire Basque health System.

• to continually align these processes at a local level with the general strategy of the Department of health and osakidetza. the idea is to develop numerous micro-systems capable of providing a level of care which is more integrated and more proactive.

¢ ¢ ¢

in conclusion, the Basque health System is embarking upon a broad transformation in order to respond to the challenge and the opportunity presented by chronic patients. this transformation is not an option, but, in fact, is a necessity in order to contribute to the sustainability of the System and to be able to provide Basque citizens with the level of care and service they need and deserve.

the achievement of this change is a mid-term challenge which is going to require a clear strategic direction, but, above all, the commitment, the energy and the innovation of the system professionals and the citizens who participate in it as patients and as carers.

Working together, a change will be set in motion in the mid term which will take time to reach fulfilment, but once started, with the participation and the commitment of all the involved parties will be unstoppable. this will also enable the Basque health System to be able to prepare for the needs of the future, contributing to financial sustainability and offering the citizens and patients the best possible health results, better satisfaction and quality of life and a service which is best adapted to meet their needs.


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Ta b l e s

table 1. list of possible chronic illnesses and their characteristics

table 2. chronicity in the Basque country

table 3. change in the prevalence of diabetes and cardiovascular disease in the Basque country

table 4. illustration of the predicted change in chronic illnesses at world level. – example Diabetes

table 5. Differences in the key success characteristics and factors in relation to chronic and acute interventions

table 6. Principal ideas of the Aicc model

table 7. interventions with evidence and examples of health systems where some of these have been implemented

table 8. A basically reactive system

table 9. complementing the level of excellence in acute care

table 10. how the system could change for the patients

table 11. expected results from the chronic illness Strategy

table 12. Strategic Policies

table 13. illustration of a possible pyramid of population stratification

table 14. example of prevention intervention

table 15. example of patient awareness and accountability intervention

table 16. illustration of continuous care

table 17. illustration of intervention adaptation

table 18. Strategic Projects within the chronic illness Strategy

table 19. Strategic Stratification Project

table 20. Strategic Project of Prevention and Promotion

table 21. Strategic Self-care and education Project for the patient

table 22. Strategic Self-care and education Project for the patient

table 23. Strategic Project of the unified Medical record

table 24. Strategic Project of integrated medical care

table 25. Strategic Project for adopting new technologies by the chronic patients associations

table 26. Strategic Project of advanced nursing competences

table 27. Strategic Socio-health collaboration Project

Index of Tables and Figures


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table 28. Strategic Project of financing and contracting

table 29. Strategic Project of Multi-channel Service centre

table 30. Strategic Project of e-prescription

table 31. Strategic Project of the chronicity research centre

table 32. Strategic Project for innovation on the part of medical professionals

table 33. integrated vision of the expected impact of the strategic projects

table 34. the need to combine strategic direction with medical and management commitment

F i g u r e s

figure 1. Prevalence (%) of chronic problems according to age and sex

figure 2. Distribution of the population aged over 65 according to the number of chronic problems

figure 3. Distribution of patients according to the number of chronic illness by age

figure 4. Main medical conditions appearing in patients with multimorbidity according to the primary care diagnosis

figure 5. change in the percentage of persons with chronic problems between 1997 and 2007 according to their age

figure 6 change in the prevalence of diabetes and cardiovascular disease in the Basque country

figure 7. number (and prevalence) of chronic patients over the age of 18 suffering from the principal pathologies

figure 8. Prevalence of the principal pathologies by age groups

figure 9. the care Model for chronic Patients

figure 10. the innovative care Model for chronic Patients

figure 11. extended kaiser’s Pyramid

figure 12. new model for the Basque health System

figure 13. Strategic diagram


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for more information regarding the general strategy and specifi c projects, please visit our web page http://cronicidad.euskadi.net

Health & Medicine

A Strategy to Tackle the Challenge of Chronicity in the Basque Country