patientoriented integrated care in vienna 14' 17' district

1
patient-oriented integrated care(in vienna 14.
- 17. district)

• christa peinhaupt, peter nowak

2
Thanks for cooperation .....

• Local project partners
• Hanusch KH
• Wilhelminenspital
• KA des Göttl. Heilandes
• Gesundheits- und Sozialzentren
• der MA 15A
• Arbeiter Samariter Bund
• Caritas Erzdiösese
• Caritas Socialis
• Sozial Global
• Volkshilfe Wien
• Wiener Hilfswerk
• Wiener Rotes Kreuz
• Wiener Sozialdienste
• Apotheken
• Niedergelassene ÄrztInnen
• Freiberufliche MTDs

• Staff of scientific team and project management
• Robert Bautzmann
• Beate Greiner
• Andreas Keclik
• Martin Nagl-Cupal
• Peter Nowak
• Christa Peinhaupt
• Christine Reidl
• Ulli Weisz
• Jürgen M. Pelikan

• Representatives of commissioner
• Susanne Herbek (BGF)
• Werner Schröder (WGKK)
• Charlotte Staudinger (KAV)

3
www.pik-wien.at
4
Overview

• Integration and patient-orientation
• Concepts deficits
• PIC Model-project Patient-oriented integrated
  care (in Vienna 14.-17. district)
• Design
• Content
• Potentials for more patient-orientation and
  integrated care in Vienna and Austria

5
Treatment gaps in health care (Krajic, Nowak,
Peinhaupt, Pelikan 2002)
intramural
extramural
out-patient
in-patient
household
social network
health care
laities
professionals (people and organisation(units)
nursing
patients
6
Integration of health care means... (following
Krajic, Nowak, Peinhaupt, Pelikan 2002)

• the negotiation of communication systems as a
  prerequisite
• for coordinated and mutual care services
• between the various professional partners and
• between patients, lay carers and professionals

7
Deficits in integrating treatment gaps for health
care professionals analytical findings from PIC

• No information about services and service
  conditions of other health care providers
• Inconsistent documentation systems
• No clearly defined transition processes
• Missing data networks
• Missing transmural medical cooperation culture
• High effort and complications in the organisation
  of medical devices (e.g. mattress for sickbeds at
  home, wheelchairs, dressing materials)
• Missing extramural resources for nursing care,
  therapists, over-night-care and specialised
  mobile services (e.g. mobile hospice)
• Missing structures for interorganisational and
  intersectoral negotiations

8
Selected data from PIC-status quo survey (1)
yes
no
9
Selected data from PIC-status quo survey (2)
Yes, others
No
Yes, by patient/relatives
Yes, by hospital staff
10
What can patient orientation mean?

• Patients health problems are solved
  professionally by health care providers
• Patients health problems are better solved
  together with patients
• Patients health problems are sustainable solved
  by patients themselves
• ... and
• Developing services by involving patients

11
Deficits in integrating treatment gaps for
patients - analytical findings from PIC

• Confusion in a complex, fragmented and not
  transparent system
• Insufficient patient orientation in the
  communication of health care professionals
  (mainly doctors)
• Insufficient transmural aligned empowerment of
  patients for illness management
• Insufficient case management
• Patient must/can not compensate missing
  information as data transfer between providers
• Appropriate balance between standardisation and
  individual treatment
• Insufficient involvement of patients in planning
  of the health care system

12
Selected data from PIC-status quo survey (3)
Did the (hospital) doctors encourage you to ask
questions related to your discharge from
hospital? (n148)
13
Selected data from PIC-status quo survey (4)
Were you or your relatives trained in practical
skills that help you to manage your illness in
everyday live? (n63)
67
14
Projectpartners
Comissioned by Vienna District Health Insurance
Fund City of Vienna Vienna Hospital Association
Health Planning and Financial Management
Scientific consulting Project
management Ludwig Boltzmann Institute for the
Sociology of Health and Medicine Austrian
Society for Theory and Practice in Health
Promotion

• Local project partners
• Patients/Carers
• Three Hospitals
• Hanusch Krankenhaus
• Wilhelminenspital
• Krankenanstalt Göttlicher Heiland
• GPs
• Home Care Services
• Pharmcies
• Therapists (freelance)

15
Project design patient involvement
Local steering committee
Over-all project group
Diagnosis related integrated care (DIC)
Integrated care for patients at home (ICH)
Integrated referral and discharge
management (IRD)
16
Project group Integrated Referral and Discharge
Management (IRD)

• Target group
• Patients without complex needs (e.g. home care
  nursing, house visits by GPs) before or after
  hospital stay
• Selected measures
• Standardised referral form
• Standardisation of information transfer for
  planned admissions
• Info folders for patients
• Information for patients, e.g. what documents
  they have to bring
• along for their hospital stay
• Improvement in organisation of medical devices
  (e.g. mattress for sickbeds at home, wheelchairs,
  dressing materials)
• round table of all sickness insurance funds,
  nomination of contact
• persons for complaints

17
Project group Integrated Care for Patients at
Home (ICH)

• Target group
• patients with complex home care needs (related
  to hospital stay)
• Selected measures
• Health Folder Integrated Care
• Collection of the most important information for
  health care professionals at treatment gaps, e.g.
  discharge letters, name and contact-address of
  all professional- and lay carers of the patient
• Status-quo-documentation nursing
• Standardised documentation for intra- and
  extramural nurses, transfer of this documentation
  in admission and discharge
• Case Management in discharge management
• Formulation of a quality standard

18
Project group Diagnosis-related Integrated Care
(DIC)

• Target group
• Patients with specific diagnosis (e.g.
  oncological patients), who frequently have to
  alternate between intra- and extramural care
• Selected measures
• Patient oriented education
• Adequate and empathetic information about a
  severe diagnosis
• Transmural coordinated patient training
• Activating and empowering involvement of patients
  in their own cure and care
• Mobile consultant service, telephone/e-mail
  consulting
• Mutual consulting and queries between hospital
  specialists and GPs concerning patients care at
  home

19
Guiding principle More patient involvement in
the project region

• Target group
• Patients and lay carers (relatives)
• Selected measures
• Internet-based information on regional care
  provision  
• Internet portal about health care providers and
  services in the project region
• Complaint management 
• Feedback system as part of the quality management
  in hospital
• Self-help groups accessible in hospital
• Agreement between self help groups and hospital
  departments for consulting of patients by members
  of self help groups during hospital stay

20
Ten potentials for innovations in Vienna
(Austria) results from the project

• Patient information
• Patient oriented communication
• Patient training
• Case management
• Discharge management
• Standardisation of documentation and
  transfer-instruments
• Improvement in organisation of medical devices
• Resources for extramural nursing and therapy
• Transmural consulting and services
• Structures for interorganisational and
  intersectoral negotiations and coordination

21
Further information
www.pik-wien.at www.univie.ac.at/lbimgs