出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Basque Health Service´s integrated intervention for multimorbid population program participates to ACT@Scale. The aging of the population and the increase in chronic patients represent a huge challenge for the sustainability of healthcare systems. Short description of practice change implemented : The public healthcare provider is Osakidetza which includes all hospitals and primary care centers organized in 13 Integrated Care Organizations ICOs. Osakidetza has a target population of more than 2 million inhabitants.Aging and chronic conditions account for 80% of the medical consultations, 75% of the total health budget. Aim and theory of change : the program follows the multi-organizational structured collaborative quality improvement methods based on Plan-Do-Study-ActPDSA cycle. Applying the PDSA methodology, the program has been working on: Define a common integrated care pathway Clarify the necessary actors and roles Standardize and systematize the process of empowering patients and caregivers and assess the empowerment impact Evaluate the care pathway effectiveness Training sessions on several aspects related to the care pathway Targeted population and stakeholders : Population based stratification identifyes Multimorbid patients. Moreover, at least two of these conditions must be diagnosed: Chronic Obstructive Pulmonary Disease COPD, diabetes mellitus both insulin-dependent and noninsulin-dependent or Congestive Heart Failure CHF. Stakeholders 34: team dynamics experts-3; internists -6; implementation experts-2; managerial team-12; Healthcare Directorate representative-1; project manager-1; local organizations representatives-9. Timeline : Three years: Baseline phase-March’16-Sept’16; Learning cycle-Sept’16-Sept’17; Coaching cycle-Sept’17-Sept’18; Dissemination phase-Sept’18-March’19 Comments on sustainability : Osakidetza runs on public founding. Multimorbid patient’s care pathway is one of the priority areas of the strategic plan that the Health Department and Osakidetza have for 2017-2020. Comments on transferability : Scale it up to a total of 12 ICOs, which in terms of number of patients means from 4944 to 14516 patients. Conclusions : The team has defined and described the roles and actions needed within the integrated care, and it has created a homogeneous pathway for multimorbid patient’s integrated care. The team has tackle down the problematic of patient empowerment. The team has been able to generate an empowerment protocol for patients/caregivers and an empowerment evaluation method has been established. Discussions : The expected result of Basque Country is to scale the program and reaching a total of almost 15000 patients by 2019. This would mean: 1- Impacting: reach critical-mass in numbers of users within the region; reduce in resources utilization 2- Engaging: get the endorsement of end-users and professionals; increase empowerment of patients and caregivers; equality of the service offered 3 Ensuring sustainability: increase the number of professionals using the service as their usual practice; the generated pathway takes into account the local resources available and the local differences in terms of organizational structure. Lessons learned : In order to achieve our aim we consider that one of the most important factors has been to build a multidisciplinary team, composed by stakeholders of distinct levels macro, meso and micro with varied roles and representatives of all organizations where the intervention was expected to be implemented. In addition, the Collaborative Methodology gave the opportunity to define the intervention needed in a structured way.
关键词：scaling-up ; integrated care ; collaborative-methodology ; stakeholder management ; service selection ; service dynamic adaptation ; citizen empowerment
