CAREWELL
HOW THE ACG RISK STRATIFICATION TOOL IS BEING USED IN THE VENETO
REGION FOR CASE FINDING PATIENTS WHO MEET THE PROJECT’S
ELIGIBILITY CRITERIA
FRANCESCO MARCHET, PROJECT MANAGER
VENETO REGION - LOCAL HEALTH AUTHORITY N.2 FELTRE
SUMMARY
• Overview of the CareWell project
• The Veneto Health and Social Care model
• The JHU ACG System and its deployment in Veneto
• The tool developed by LHA Nr.2
• Lessons learned
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PROJECT OVERVIEW
• CareWell aims to enable the delivery of integrated healthcare to frail
elderly patients through comprehensive multidisciplinary
programmes.
• ICTs will facilitate the coordination and communication of healthcare
professionals and support patient centred delivery of care at home.
• The project supports the integration of care in six European Regions.
• The CareWell project is co-funded by the European Commission
within the ICT Policy Support Programme of the Competitiveness
and Innovation Framework Programme (CIP).
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CAREWELL VISION
Objective: provision of integrated care for frail elderly patients
through ICT enabled healthcare services coordination, patient
monitoring, patients self-management and informal care givers
involvement.
Target population: older people who have complex health and social
care needs, are at high risk of hospital or care home admission and
require a range of high-level interventions due to their frailty and
multiple chronic diseases.
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CAREWELL APPROACH
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CAREWELL TARGET POPULATION
PALLIATIVE$CARE,$
CARE$COORDINATION$ $$
CASE$MANAGEMENT
CARE$COORDINATION
DISEASE/CASE$
MANAGEMENT
DISEASE$
MANAGEMENT
DIAGNOSIS
HEALTH$
PROMOTION$
SCREENING
End$of$life
Multimorbidity
and$complexity
Single# complex disease,
Multiple#simple conditions
Single# non3complex condition
Symptoms development
In##good health
• Age ≥65 years
• At least 2 chronic diseases
(COPD, Diabetes and/or
CHF]
• Fulfilling local/national criteria
of frailty: increased
vulnerability, complex health
needs and at high risk of
hospital or care home
admission
• Able to understand and to
comply with study
instructions and requirement
independently or with the
help from a carer
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CAREWELL PARTNERS
• Kronikgune (SP)
• Osakidetza (SP)
• Powys Health Board (UK)
• Institute of Rural Health (UK)
• Puglia Region (IT)
• HDFEZ Farmakoekonomika (CR)
• Lower Silesian Marshal’s Office (PO)
• Veneto Region (IT)
• Region Syddanmark (DK)
• Empirica (GE)
• HIM SA (BE)
• Ericsson (HR)
• Faculty of Electrical Engineering (HR)
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THE VENETO’S SOCIAL AND HEALTH CARE SYSTEM
• Veneto Region delivers healthcare and social care through 23 Local Health
Authorities and 2 Hospital trusts that compose the Veneto Region’s Social
and Health Care System.
• The Veneto’s Model of Care has a long history of integration between health
care and social care, in fact since 1992 the local branch of the Region in the
field of care are called Local HEALTH and SOCIAL Authorities.
• Veneto has also been striving for the integration between primary and
secondary care. The Local Health and Social Authorities manage both
Hospitals and Districts, functional structures that manage primary cares, (GP,
Nursing Homes, Home Nursing Services, Social Services…).
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THE LOCAL HEALTH AUTHORITY NR.2 OF FELTRE
• The Veneto’s pilot site of CareWell is hosted at
Local Health and Social Authority N.2 of Feltre
[ULSS N.2], supported by Consorzio
Arsenàl.IT, Veneto’s research centre for ehealth
Innovation.
• ULSS N.2 covers a mountainous area of 935 km2, serving 85.000
inhabitants. The 23% of the population is over 65 years old and
the 11% is over 75. The Ageing index is 177%.
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THE LOCAL HEALTH AUTHORITY NR.2 OF FELTRE
• ULSS N.2 delivers health and social care through a second level
hospital (400 beds), an hospice (7 beds), a physical rehabilitation
center (45 beds), a functional structure dedicated to the needs of
primary health care, elderly care and social care called “Social and
Health District”. More than the 14% of the over 65 y.o. population
receives In-home cares, from the Social and Health District
professionals.
• ULSS N.2 coordinates also 56 GPs, 10 pediatricians, 24 pharmacies
and the activities of 15 nursing and care homes (both public and
private), hosting about 1200 citizens.
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INTRODUCING THE ACG SYSTEM
ACG [Adjusted Clinical Group] is a population grouper used for risk adjustment
developed by Johns Hopkins University in Baltimore [USA] with 3 key goals:
• Stratify the population and their risk;
• Integrating data to integrate points of health service delivery;
• Improve care coordination for persons with multi-morbidity.
The main strengths of the ACG System are:
• Population focused
• Evidence based
• Comprehensive
• Personalized
• Inter-sectorial approach
• Continuity
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PERSON CENTERED DATA COLLECTION
Disease registries
Hospital discharge data
(ICD9)
(ICD9CM)
Emergency Room
Mental Health
Database (ICD10)
(ICD9CM)
Nursing homes &
Hospice (ICD9CM)
Home care
(International
Classification for
Primary Care - ICPC)
PERSON
Rare disease registry
(ICD 9)
Drugs (ATC)
Costs & tariffs
(DRGs, tariffs, drug costs)
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REFLECTING THE CONSTELLATION OF HEALTH PROBLEMS
EXPERIENCED BY A PATIENT
Time Period (e.g., 1 year)
Treated Morbidities
Diagnostic Codes
Visit 1
Code A
Morbidity Groups
ADG10
Code B
Visit 2
Code C
ADG21
Visit 3
Code D
ADG03
Clinician Judgment
Clinical Grouping
93 ACG
Categories
Age and gender
6
RUBs
categories
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INTEGRATION OF DATA FOR INTEGRATED CARE
DISEASE :
POPULATION
• Diagnoses (EDC, major EDC)
• Drugs (RxMG, major RxMG)
DIAGNOSES
DISEASE BURDEN
DRUGS
- COSTS
- RESOURCE USE
- TREATMENTS
ACG
SYSTEM
• ADG (Aggregated Diagnosis Groups)
• ACG (Adjusted Clinical Groups)
• RUB (Resource Utilization Bands)
FUTURE USE OF RESOURCES
• Future cost prediction
• Probability of high cost
• Probability of hospital admission
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THE STRATIFICATION OF THE POPULATION
PALLIATIVE0 CARE,0
CARE0 COORDINATION0 00
RUB%5
WEIGHT%10,2%%%
5=0
End0of0life0=001%0
CASE%MANAGEMENT
CARE% COORDINATION
40=0Multimorbidity and0
complexity =030%
RUB%4
WEIGHT'5,1'''
DISEASE/CASE%
MANAGEMENT
30=0Single0complex disease,0
Multiple0simple conditions =017%
RUB'3
WEIGHT'2,4''
DISEASE%MANAGEMENT
2#=#Single#non!complex condition 16%00
RUB'2
WEIGHT'0,9'''
DIAGNOSIS
1#=#Symptoms development =##44#%
RUB'1
WEIGHT'0,3
HEALTH%PROMOTION%
SCREENING
0=#In##good health=##18%
RUB'0
WEIGHT'0'''
HEALTH MANAGEMENT TOOLS
LOCAL WEIGHTS = COSTS
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STRATIFICATION & USE OF RESOURCES
% POPULATION
% TOTAL COSTS
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USING A POPULATION RISK-ADJUSTMENT TOOL TO INTEGRATE HEALTH SERVICE DELIVERY IN REGIONE VENETO Pilot 2012-2013: 2 LHAs (1 mln inhabitants)
• Local database building
• Statistical validity
• Study on GP databases integration
Initial Deployment 2013-2014: 6 LHAs (2 mln)
• Retrospective analysis on markers
• Analysis on specific chronic conditions
• Predictive modeling for hospitalization
• Interface of ACG with BI tools
Mainstreaming 2014-2015: 21 LHAs (5 mln)
• Regional database building
• Support to case management for chronic
patients in primary care
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USING A POPULATION RISK-ADJUSTMENT TOOL TO INTEGRATE HEALTH SERVICE DELIVERY IN REGIONE VENETO Pilot 2012-2013: 2 LHAs (1 mln inhabitants)
• Local database building
• Statistical validity
• Study on GP databases integration
Initial Deployment 2013-2014: 6 LHAs (2 mln)
• Retrospective analysis on markers
• Analysis on specific chronic conditions
• Predictive modeling for hospitalization
• Interface of ACG with BI tools
Mainstreaming 2014-2015: 21 LHAs (5 mln)
• Regional database building
• Support to case management for chronic
patients in primary care
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THE TOOL
ULSS N.2 has implemented a stratification of patients through casemix and risk adjustment software John Hopkins University ACG
combined with a powerful business intelligence tool such as QlikView.
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THE TOOL
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THE TOOL
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THE TOOL
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THE TOOL
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THE TOOL
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THE TOOL
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THE TOOL
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LESSONS LEARNED
• Huge amount of data registered for administrative purposes
has become a gold mine to support integrated care. • Entering data without any feedback can be annoying, but by
giving to clinicians and strategist, a valuable return can
increase the accuracy enabling a virtuous circle of
cooperation. • In order to integrate care it is fundamental to start to
integrate projects and experiences as in this case: the results
of combining different efforts gives back not only a bare sum
of them… 27
THANKS TO
• The CareWell Project Consortium and its coordination team
lead by Kronikgune;
• Dr. Maria Chiara Corti, dr. Massimo Fusello and the ACG
Working Group of Veneto Region;
• The local implementation team at ULSS N.2 Feltre.
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[email protected]
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