出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Integrated care has become the focus of the continuity of care. Professionals need follow-up on their role in integrated clinical management. To this end, a scorecard is being built from Primary Care PC, which also aims to make itself known to hospitals. Description of policy context and objective : This project is part of the strategy of care for patients with chronic diseases in the community of Madrid and is part of a management project aimed at developing specific scorecard aimed at clinical management. Objective : Design a scorecard to help the professional in the integrated clinical management of patients with relevant chronic diseases Targeted population : Is the people with a diagnosis of relevant chronic pathology identified at a population level in the community of Madrid. General Practicioners, Pediatrics and Nursing will have access to consult the indicators of their atended people by separating the information at the patient level. In hospitals, aggregate information will be provided to t directors of Their continual care. Highlights : We have defined work phases to develop in the Comprehensive Scorecard of PA to monitor the impact of implanting the chronic strategy: - Design of indicators oriented to intermediate health results of the attended patients in the last year by relevant chronic pathology. 17 indicators of avoidable hospitalization and re-entry to 30 days have been constructed. 2017. Eg 27.7% of patients with HF and avoidable admission and 9.53% in patients with COPD. - Construction of indicators to monitor the level of intervention assigned by professionals to citizens with relevant chronic pathology. The population-level risk is calculated annually for each person. The intervention level is an individual variable assigned by the professional based on the care need generated. Currently, all chronic patients have a population- level risk identified in the clinical history.14% has an intervention level assigned by the professional and 8% of patients with hight risk has been assigned a hight intervention level by the professional. In the last estratification process made in decembre 2017 the level assigned have increased in the groups with the most level risk. - Restructuration of the Primary Care scorecard so that the Directors of continual care of all the 32 hospitals in Madrid have this aggregate information whithin their population of influence. 2018 - Redesign of the evaluation of the AP standardized service portfolio process measure adapted to the levels of intervention in chronic pathology 2019 - Research other intermediate health results through the constitution of a working group composed of agents involved. 2018 and 2019 Comments on transferability : It is transferable to another community that has the AP's medical history computerized Conclusions including key findings, discussion and lessons learned : To guarantee the implementation of a strategy, it is essential to provide feedback on the progress made. Show results and involve professionals in the information they need, it's key to see improvement and grouth integrated management. The results show that we are in the initial phases of the implementation of the chronic strategy in the follow-up with the indicators.
关键词：scorecard ; integrated care ; indicator ; primary care
