Monday, 7 September 2015

"Patient Centred Coordination" a CCM evolution

Edward Wagner, the creator of the Chronic Care Model (CCM), when asked why he promoted a new system, responds. "The initiative came from my own clinical practice. For me, it was frustrating to see how well prepared and well-meaning doctors, were not achieving good results when dealing with the care of chronic patients, while we were starting to see evidence that by doing things differently, patients could better understand what happened to them and clinical outcomes could improve. And for this reason I thought it appropriate to communicate these new findings with the doctors "(The full interview can be found in the post "The chronic model: The Wagnerian Keys").

The current care model for complex chronic patients is usually based on individualized care plans developed for each sector: the primary care teams generally have individualized plans (ICP-PCT in the graphic), the municipal social services also work with customized plans (ICP-MSS) linked to the service portfolio of the dependence law; the long-term centers, meanwhile, develop their specific plans for each admitted patient (ICP-LTC), whereas in nursing homes, healthcare professionals who work there tend to write different plans for each resident (ICP-NH).

The efforts to harmonize these plans and facilitate circuits are difficult, but where is the problem? Well, it's not difficult to guess that the difficulties arise due to the fragmented structure of services, which causes that each individual care plan meets the criteria and the particular vision of each sector.

Patient Centred Coordination (PCC), and not in the loop 

The key piece of Chronic Care Model (CCM) is at the bottom of the graph, when productive interactions between active and knowledgeable patients (left)  and a team of professionals who perform a proactive practice being well prepared to do so (right) are related. Therefore, if this model is adopted, we’re not talking about launching  heavy coordination meetings to improve circuits, but about  promoting a methodology based on teamwork.

Two key aspects of the PCC
  1. One person in the professional team (a tutor) should know the patient well and first hand, starting with their values ​​(what he thinks about his life and how he lives it); his social and family situation, as well as, of course, his clinical circumstances, cognitive first.
  2. The patient must have a unique access point into the system. Therefore, the professional team is required to develop a joint individualized care plan (JICP) for each patient, plan that must count on the commitment of all actors that sooner or later, will have to act or provide care to the patient.
The socio-clinical sessions

A PCC’s par excellence working instrument is constituted by the socio-clinical sessions: an unsophisticated methodology, which consists of regular, well prepared and well scheduled meetings where the agenda will only include the names of patients who are subject to professional debate, in order to develop a joint individualized care plan (JICP) for each. This model had already been applied for many years in tumour committees in the hospitals and in the circuit meetings of mental health network with considerable success.

Socio-clinical sessions procedure

The sessions should be attended by all professionals that, at some point in the care path, are expected to have a role to perform, whether it’s a professional from the primary health care, a social workers of the council or a hospital specialist. The geriatrician chosen by the hospital should be a permanent element in the socio-clinical sessions, in addition to performing a link function to insure the involvement of other specialists when this is deemed necessary.

The model of Patient Centred Coordination (PCC) features a very simple methodology: development of individualized treatment plans for each complex chronic patient, in a joint manner, by professionals at any level or sector, which at one time or another must offer services to that person. If the PCC meeting is attended by everyone who should attend surely the results will be better than the ones produced by the current fragmentation.

Jordi Varela

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