Title: patientoriented integrated care in vienna 14' 17' district
1patient-oriented integrated care(in vienna 14.
- 17. district)
- christa peinhaupt, peter nowak
2Thanks for cooperation .....
- Local project partners
- Hanusch KH
- Wilhelminenspital
- KA des Göttl. Heilandes
- Gesundheits- und Sozialzentren
- der MA 15A
- Arbeiter Samariter Bund
- Caritas Erzdiösese
- Caritas Socialis
- Sozial Global
- Volkshilfe Wien
- Wiener Hilfswerk
- Wiener Rotes Kreuz
- Wiener Sozialdienste
- Apotheken
- Niedergelassene ÄrztInnen
- Freiberufliche MTDs
- Staff of scientific team and project management
- Robert Bautzmann
- Beate Greiner
- Andreas Keclik
- Martin Nagl-Cupal
- Peter Nowak
- Christa Peinhaupt
- Christine Reidl
- Ulli Weisz
- Jürgen M. Pelikan
- Representatives of commissioner
- Susanne Herbek (BGF)
- Werner Schröder (WGKK)
- Charlotte Staudinger (KAV)
3www.pik-wien.at
4Overview
- Integration and patient-orientation
- Concepts deficits
- PIC Model-project Patient-oriented integrated
care (in Vienna 14.-17. district) - Design
- Content
- Potentials for more patient-orientation and
integrated care in Vienna and Austria
5Treatment gaps in health care (Krajic, Nowak,
Peinhaupt, Pelikan 2002)
intramural
extramural
out-patient
in-patient
household
social network
health care
laities
professionals (people and organisation(units)
nursing
patients
6Integration of health care means... (following
Krajic, Nowak, Peinhaupt, Pelikan 2002)
- the negotiation of communication systems as a
prerequisite - for coordinated and mutual care services
- between the various professional partners and
- between patients, lay carers and professionals
7Deficits in integrating treatment gaps for health
care professionals analytical findings from PIC
- No information about services and service
conditions of other health care providers - Inconsistent documentation systems
- No clearly defined transition processes
- Missing data networks
- Missing transmural medical cooperation culture
- High effort and complications in the organisation
of medical devices (e.g. mattress for sickbeds at
home, wheelchairs, dressing materials) - Missing extramural resources for nursing care,
therapists, over-night-care and specialised
mobile services (e.g. mobile hospice) - Missing structures for interorganisational and
intersectoral negotiations
8Selected data from PIC-status quo survey (1)
yes
no
9Selected data from PIC-status quo survey (2)
Yes, others
No
Yes, by patient/relatives
Yes, by hospital staff
10What can patient orientation mean?
- Patients health problems are solved
professionally by health care providers - Patients health problems are better solved
together with patients - Patients health problems are sustainable solved
by patients themselves - ... and
- Developing services by involving patients
11Deficits in integrating treatment gaps for
patients - analytical findings from PIC
- Confusion in a complex, fragmented and not
transparent system - Insufficient patient orientation in the
communication of health care professionals
(mainly doctors) - Insufficient transmural aligned empowerment of
patients for illness management - Insufficient case management
- Patient must/can not compensate missing
information as data transfer between providers - Appropriate balance between standardisation and
individual treatment - Insufficient involvement of patients in planning
of the health care system
12Selected data from PIC-status quo survey (3)
Did the (hospital) doctors encourage you to ask
questions related to your discharge from
hospital? (n148)
13Selected data from PIC-status quo survey (4)
Were you or your relatives trained in practical
skills that help you to manage your illness in
everyday live? (n63)
67
14Projectpartners
Comissioned by Vienna District Health Insurance
Fund City of Vienna Vienna Hospital Association
Health Planning and Financial Management
Scientific consulting Project
management Ludwig Boltzmann Institute for the
Sociology of Health and Medicine Austrian
Society for Theory and Practice in Health
Promotion
- Local project partners
- Patients/Carers
- Three Hospitals
- Hanusch Krankenhaus
- Wilhelminenspital
- Krankenanstalt Göttlicher Heiland
- GPs
- Home Care Services
- Pharmcies
- Therapists (freelance)
-
15Project design patient involvement
Local steering committee
Over-all project group
Diagnosis related integrated care (DIC)
Integrated care for patients at home (ICH)
Integrated referral and discharge
management (IRD)
16Project group Integrated Referral and Discharge
Management (IRD)
- Target group
- Patients without complex needs (e.g. home care
nursing, house visits by GPs) before or after
hospital stay - Selected measures
- Standardised referral form
- Standardisation of information transfer for
planned admissions - Info folders for patients
- Information for patients, e.g. what documents
they have to bring - along for their hospital stay
- Improvement in organisation of medical devices
(e.g. mattress for sickbeds at home, wheelchairs,
dressing materials) - round table of all sickness insurance funds,
nomination of contact - persons for complaints
17Project group Integrated Care for Patients at
Home (ICH)
- Target group
- patients with complex home care needs (related
to hospital stay) - Selected measures
- Health Folder Integrated Care
- Collection of the most important information for
health care professionals at treatment gaps, e.g.
discharge letters, name and contact-address of
all professional- and lay carers of the patient - Status-quo-documentation nursing
- Standardised documentation for intra- and
extramural nurses, transfer of this documentation
in admission and discharge - Case Management in discharge management
- Formulation of a quality standard
18Project group Diagnosis-related Integrated Care
(DIC)
- Target group
- Patients with specific diagnosis (e.g.
oncological patients), who frequently have to
alternate between intra- and extramural care - Selected measures
- Patient oriented education
- Adequate and empathetic information about a
severe diagnosis - Transmural coordinated patient training
- Activating and empowering involvement of patients
in their own cure and care - Mobile consultant service, telephone/e-mail
consulting - Mutual consulting and queries between hospital
specialists and GPs concerning patients care at
home
19Guiding principle More patient involvement in
the project region
- Target group
- Patients and lay carers (relatives)
- Selected measures
- Internet-based information on regional care
provision - Internet portal about health care providers and
services in the project region - Complaint management
- Feedback system as part of the quality management
in hospital - Self-help groups accessible in hospital
- Agreement between self help groups and hospital
departments for consulting of patients by members
of self help groups during hospital stay
20Ten potentials for innovations in Vienna
(Austria) results from the project
- Patient information
- Patient oriented communication
- Patient training
- Case management
- Discharge management
- Standardisation of documentation and
transfer-instruments - Improvement in organisation of medical devices
- Resources for extramural nursing and therapy
- Transmural consulting and services
- Structures for interorganisational and
intersectoral negotiations and coordination
21Further information
www.pik-wien.at www.univie.ac.at/lbimgs