Description of pathway components. The following description relates to the components of the pathway as described in section 2.2 above, with each heading corresponding to one of the boxes in the pathway. Again, differences between the two pathways are highlighted, with elements referring only to the short- term pathway being marked as “ ICP-Short ”, and elements referring to the long-term care pathway as “ ICP-LTCare ”. Elements not specifically marked apply to both pathways. There will be three different entry points for Clients in an acute situation (after hospitalisation, surgery, early discharge or any acute episode, including social issues): • Discharge from the hospital/health care centre: after a hospitalisation, surgery, early discharge. • Referral from the CLAS or any organisation belonging to CLAS, namely Social Security and Amadora Municipality: identification of elderly people living alone in need of home care support due to several and emergent constraints related to mobility and/or subsistence; and/or identification of clients being monitored for social & health reasons by other organisations but that could benefit from BeyondSilos workflow. • Referral by Client itself or by any relatives: incapacity to continue living without social & health support. When the actors above identify a client(s) with an acute episode regarding social and/or health care, they can trigger the process of referral to SCMA Home Care Support Service (HCSS). After that, the Coordination Team of HCSS, composed of nurses and social workers, will evaluate the situation, and in case of need, enrol the client into BeyondSilos workflow. If the Coordination Team considers that the potential client needs any different type of response, such as permanent assistance, or partial but on-site assistance, they can refer to other social & health services of SCMA, such as nursing homes, continuing care unit, or day care centre. There will be two entry points for CRs with a chronic situation (worsening of health status: heath failure; COPD; and/or worsening of social situation: living alone with no primary or secondary network; lack of means of subsistence or mobility): • Discharge from hospital / nursing home / day care centre / Care Continuing Unit. It is expected that an increase in the quality of home care – due to training-induced improvement of care skills and/or improved tele-assistance and telemonitoring – will support an increase in the number of services provided at home, permitting people currently living i...
Description of pathway components. The following description relates to the components of the pathway as described in section 2.2 above, with each heading corresponding to one of the boxes in the pathway. Again, differences between the two pathways are highlighted, with elements referring only to the short- term pathway being marked as “ ICP-Short ”, and elements referring to the long-term care pathway as “ ICP-LTCare ”. Elements not specifically marked apply to both pathways. Entry points There is mainly one starting point for this acute ICP. It would be when a patient has been referred to the BeyondSilos programme by: • Any of the primary care centres of BSA. • Badalona’s municipal hospital. • Social health centre “El Carme”. • Badalona’s City Council Social Services. • BSA’s Home Care Department. Potential participants suggested to be involved in the BeyondSilos programme, most probably after a hospitalisation, surgery, early discharge or any acute episode (including social issues) by any of these units will have to go through an evaluation performed by the Case Managers of BSA who are composed mainly of nurses and social workers. Each Primary Care Centre and also the Hospital and the Social Health Centre do have their own Case Managers that are specialised in evaluating with their interdisciplinary teams the health and social risks of each individual, and subsequently arranging the needed services for each particular situation. They are the ones that will decide if the participant is likely to be included in the BeyondSilos programme. There are two entry points for this LTCare ICP. The first is when a patient has been referred to the BeyondSilos programme by: • Any of the Primary Care Centres from BSA. • Badalona’s municipal hospital. • Social health centre “El Carme”. • Badalona’s City Council Social Services. • BSA’s Home Care Department. Potential participants proposed for the BeyondSilos programme by any of these units will have to go through an evaluation performed by the Case Managers of BSA, who are mainly nurses and social workers. Each Primary Care Centre and also the hospital and the Social Health Centre have their own Case Managers that are specialised in evaluating, with their interdisciplinary teams, the health and social risks of each individual, and subsequently initiating the needed services for each particular situation. They are the ones that will decide if the participant is likely to be included in the BeyondSilos programme. The second starting point would be when th...
Description of pathway components. The following description relates to the components of the pathways as described in section 2 above, with each heading corresponding to one of the boxes in the pathway. Entry point: In Campania deployment site, the entry points for CRs having a chronic situation (living alone; on a dependency situation; worsening of social and/or health status) are: • Discharge from hospital. • Referral from the AUIC, GPs, Department of preventive medicine, or any organisation belonging to ADI. When the actors above identify a client that has social and health care needs, they trigger the process of referral to AUIC. After assessment, and if the client meets the enrolment criteria, they enrol the client in the BeyondSilos service. Alternatively, they leave it to the regular ADI. A limited number of patients will be enrolled in the BeyondSilos service. Once this number is reached, new candidate clients will be registered that will receive standard ADI, but will serve as possible outcome controls. • Clients referred to the AUIC will be subject to: • Evaluation of social care and health care needs by the BeyondSilos team. • Preparation and application of a dedicated health and social care work programme, corresponding to one of the existing three levels of intensive care identified by the Italian health and social care system (see above for further explanation). Two different types of care should encompass the following services/activities:
a) Social Care • Accompaniment for administrative purposes • Accompaniment to /in hospital • Accompaniment at home • Administrative tasks • Home care support • Cleaning • Follow-up schedule. • Wheel chair / crutch / articulated bed loan • Psychological service • Coordination healthcare centre / hospital • Coordination with NGO • Other support, information or resources management
b) Healthcare • Remote monitoring: the most common devices installed are: blood pressure meter, Oximeter, weight scale, glucometer, thermometer and behavioural analysis through movement sensors. • Complex geriatric treatment • Convalescence • Tests and special treatments (such as blood tests, etc.) • Medication adherence • Rehabilitation at home (delivered by physiotherapists) • Health transportation • Emergency transfers • GP or nurse home assistance • Wound care • Forms filling to detect alert signs CR can benefit from one or both services, depending on the profile evaluation. In BeyondSilos, however, CRs in need of social and health care support are included. CR...
Description of pathway components. The following description relates to the components of the pathway as described in section 2.2 above, with each heading corresponding to one of the boxes in the pathway. Entry point: In Gesundes Kinzigtal deployment site, there will be two different entry points for the patient after an acute episode. First entry point is after discharge from hospital, when the hospital doctor decides to provide home care services for the patient for a certain time, because he supposes that the patient is at social risk of any type. After the health insurance company permits the provision of a short term care service, the patient or his relatives, together with the home care provider, discuss the particular activities and benefits. Second entry point is a social event such as the patient visit to a doctor's practice. If the GP suspects a patient to be at risk, for example because of an acute event (superficial stroke, fall) or needs a high communication level, the GP can decide that home care service should be provided for a predetermined time. After the health insurance permits the short term care, the GP or the patient / relative gets in touch with the responsible home care provider. Of course, a social event can also mean the entry point through relatives, the suffering person himself, or other informal carers. There will also be two different entry points for the patient in long term care. First entry point is the patient visit to a doctor's practice. If the GP suspects a patient to be at risk, for example because of an acute event (superficial stroke, fall) or needs a high communication level, the GP can decide that home care service should be provided for a determined time. After the health insurance agrees to the short term care, the GP or the patient/relative gets in touch with the responsible home care provider. Second entry point is when a relative or the patient himself takes the decision to order social care support because neither the patient nor the relative are able to handle the situation themselves. After the permission of the health care insurance, the patient or relative get in touch with an outpatient social care provider for a first consultation.
Description of pathway components. The following description relates to the components of the pathway as described in section 2.2 above, with each heading corresponding to one of the boxes in the pathway. Differences between the two pathways are highlighted, with elements referring only to the short-term pathway being marked as “ ICP-Short ”, and elements referring to the long-term care pathway as “ ICP- LTCare ”. Elements not specifically marked apply to both pathways. Referral into the service will usually be from a hospital, but may be from another source if a CR is noted to be declining and requires a reablement / rehabilitation service to keep them out of an acute facility. Possible sources of referral are: • GP: If, following a Risk Stratification process of all patients on a GP's list, the patient is amongst the highest risk strata, then GP practice will initiate the process of compiling a personalised Integrated Care Plan for the patient in the NIECR. • District nurse. • Professions Allied To Medicine e.g. physiotherapists, speech therapists, occupational therapists, podiatrists. • Social care. • Client / family / carer. Referral into the service could be from a number of sources, and may be after the patient has been on the acute / reablement pathway for six weeks: • Hospital. • GP. • District nurse. • Professions allied to medicine e.g. physiotherapists, speech therapists, occupational therapists, podiatrists. • Social care. • Client / family / carer. Referral is made by telephone directly into a call management centre where an on-line referral is completed, describing: • Name. • Address. • Health Care Number (HCN) – unique identifier. • Next of Kin details. • GP details. • Free text – reason for referral. • Referrers details.
Description of pathway components. The following description relates to the components of the pathway as described in section 2.2 above, with each heading corresponding to one of the boxes in the pathway. Again, differences between the two pathways are highlighted, with elements referring only to the short- term pathway being marked as “ ICP-Short ”, and elements referring to the long-term care pathway as “ ICP-LTCare ”. Elements not specifically marked apply to both pathways. pathway for There are three starting points for an elderly person to enter the integrated acute short-term care: a referral from the Divaro Medical centre (based on the recommendations in the hospital discharge latter), from Arcadia, or the public social services in Sofia Municipality, where the acute condition was treated. There are two ways for inclusion: medical evaluation and referral from a physician (at Divaro), or social evaluation and referral by a social worker (at Arcadia or the state social service). Potential care recipients proposed for the BeyondSilos programme will most probably be patients after a hospitalisation, surgery, early discharge or any acute episode, which will require a combination of medical follow-up and social assistance at home for a period of 30 days. This time period is selected on the basis of scientific literature review and available definitions, and is common sense from a medical perspective. Patients could then be enrolled into the long term integrated care providing that they meet the eligibility criteria. Referrals will be considered by the BeyondSilos Evaluation Commission formed by CPRH; the Commission will propose potential CRs for admission to the integrated system and care. There are several starting points for an elderly person to enter the integrated pathway for long term care: a referral from Divaro medical centre, or a referral from Arkadia or the public social services in Sofia municipality. We also consider a discharge from hospital or a social institution to be possible entry points. There are two ways for inclusion: medical evaluation and referral from a physician (at Divaro), or social evaluation and referral by a social worker (at Arkadia or the state social service). The referrals will be considered by the BeyondSilos Evaluation Commission formed by CPRH; the commission will propose to potential CR for admission to the integrated system. Another entry point is the continuation from Short-term pathway.
Description of pathway components. The following description relates to the components of the pathway as described in section 2.2 above, with each heading corresponding to one of the boxes in the pathway. Again, differences between the two pathways are highlighted, with elements referring only to the short- term pathway being marked as “ ICP-Short ”, and elements referring to the long-term care pathway as “ ICP-LTCare ”. Elements not specifically marked apply to both pathways.
