出版社：Utrecht University, Maastricht University, Groningen University
摘要：One of the most problematic interfaces is the hospital-community care interface.[1] Older persons discharged from acute care hospitals are at risk of 30-day hospital readmission and death.[2] "Integrated Care" purports to address the problem, although, to date, a comprehensive solution has not yet been achieved.[3] A new H2020 project – "CONNECARE" aims to develop and evaluate a new organisational model for Integrated Care for complex patients enabled by ICT tools. Some of the building blocks for the new integrated care model are in advanced stages of implementation by some of the consortium partners. An example of this is Assuta Medical Centers and its mother organization, Maccabi Healthcare Services (Israel): Maccabi has an integrated community care system with a central Electronic Medical Record, used by all healthcare professionals, with patients' access to their record through a patient portal. The clinical decision support system facilitates integration among providers in the community and their patients. Assuta's hospital network has a central EMR and there is two-way access to patient records between community and hospital In May 2015, Maccabi implemented a nationwide Continuity of Care program that provides integrated follow up care for all complex patients discharged from the hospital, supported by a digital platform that defines each provider’s tasks and enables follow up to assure that tasks are completed through seamless interface with the patient’s EMR. A preliminary evaluation based on the first 6 months of operation (July-December 2015) found that: Patients who received integrated care had a 4% reduction in hospital readmissions compared with those who did not receive coordinated care. There was a reduction in hospital care costs of 32% for Maccabi members identified as complex co-morbid patients due to the intensity of the intervention in the community i.e. homecare visits, or visits to primary care Patients expressed high levels of satisfaction with their care. Assuta is building an integrated health and care system in Ashdod in partnership with Maccabi and the Municipality that will begin in Spring, 2017, with dedicated Care Managers responsible for integrating the care for the patient in the hospital, and with community healthcare services and the Municipality's Social Services. As consortium partners in CONNECARE, the Assuta/Maccabi processes will be supported by the CONNECARE model for complex patients with additional digital tools including a platform for care coordination and a Self-Management System for patients and carers. The CONNECARE digital platform will be ready for implementation by Autumn 2017, coinciding with the implementation of the Assuta Ashdod Integrated care system. The CONNECARE pilots will enable a robust evaluation of this integrated care model, not only in Israel but in Spain and the Netherlands, thus providing a foundation for a potentially transferable solution. References : 1- Mur-Veeman, I., Van Raak, A., & Paulus, A. Comparing integrated care policy in Europe: Does policy matter?. Health Policy, 2008;85(2):172-183. 2- Gerhardt G, Yemane A, Apostle K, Oelschlaeger A, Rollins E, Brennan N. Evaluating whether changes in utilization of hospital outpatient services contributed to lower Medicare readmission rate. Medicare Medicaid Res Rev 4(1). 2014. 3- Ouwens, M., Wollersheim, H., Hermens, R., Hulscher, M., & Grol, R. Integrated care programmes for chronically ill patients: a review of systematic reviews. International journal for quality in health care, 2005;17(2):141-146.
