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Objective: Implementation of an advance care planning (ACP) program for people with advanced chronic conditions is a complex process. The aims of this paper are to describe (1) the development of the ACP program in Catalonia, Spain, for patients with advanced chronic conditions and complex needs and (2) the preliminary results of the implementation of this program in health and social services.Method: The ACP program was developed and implemented in a four-stage process as follows: (1) design and organization of the project; (2) selection of the professionals to carry out the project; (3) creation of four working groups to develop the conceptual model, guidelines, training program, and perform a qualitative evaluation; and (4) project implementation.Result: The following deliverables were completed: (1) conceptual framework document; (2) practical guidelines for the application of the ACP; (3) online training course (3,763 healthcare professionals completed the online course, with an overall satisfaction rating of 8.4 on a 10-point scale); and (4) additional training activities (conferences, short courses, and seminars) in between 2015 and 2017.Significance Of Results: This project was led by the Catalan Ministry of Health. The strengths of the project development include the contribution of a wide range of professionals from the entire region, approval by the Catalan Bioethics Committee and the Social Services Ethics Committee, and the ongoing validation by members of the community. A standardized online training course was offered to all primary care professionals and included as a quality indicator for continuing education for those professionals in the period 2016-2020. The main outcome of this project is the establishment of a pragmatic ACP throughout the region and training of the health and social care professionals involved in the care of advanced chronic patients. [ABSTRACT FROM AUTHOR]

Disease-related malnutrition (DRM) is a prevalent condition amongst older people as well as patients in all healthcare settings around the world. Chronic patients with complex health needs (CPCHN defined as those with complex chronic conditions that involve multiple health requirements, complex social support needs, or both) are especially vulnerable to malnutrition. Malnutrition is associated with increased morbidity, a higher hospital admission and readmission rate, increased needs for social resources and even a high mortality. In Catalonia, CPCHN account for 3.5-5% of the Catalan population (250,000 to 375,000 patients), and we have data pointing to a high prevalence of malnutrition in CPCHN admitted in hospitals for an acute episode (36% malnourished, 47% risk of malnutrition). Nevertheless, the prevalence of DRM in CPCHN in the community has been not sufficiently studied. In addition, health and social risk factors for malnutrition are unknown in these population. Taking all these into account, it is necessary to establish an integrated and a collaborative health and social strategy for the screening and management of nutritional care, mainly from a community-based as well as a patient-centered approach. The strategy to tackle against malnutrition in CPCHN is led by the Department of Health of Catalonia (PPAC, PIAISS), the Spanish Society of Parenteral and Enteral Nutrition (SENPE) and the Family and Community Nursing Association (AIFICC), with the support of the University of Vic. This strategy is based on a Decalogue of actions to fight against malnutrition previously identified by a consensus among experts from scientific societies, social services and public health, incorporating the vision of patients and caregivers. Aims: 1. Highlight the DRM problem in CPCHN launching a prevalence study of DRM in the CPCHN selecting a representative sample of Catalonian society. 2. Establish an integrated and a collaborative intervention plan (nutritional and social) linked to the detection of malnutrition and/or social dysfunction. Results and impact: 1. The prevalence study of DRM in the CPCHN is a prospective observational and multicenter randomized study that has been performed in a region of Catalonia, representative of the Catalan society (80% urban, 20% rural). The sample size calculated was 384 patients, a total of 404 patients have been participated. A very high prevalence of malnutrition and risk of malnutrition has been found (46.5% risk, 5.9% malnutrition) Living alone, polypharmacy and dysphagia were the most important social and health determinants that influence DRM and will allow us to focus strategies to improve patient care. 2. The integrated and collaborative intervention plan to tackle against DRM in CPCHN is based on a protocol that includes the clinical, nutritional and social risk screenings. With this aim, Primary Care teams (doctors and nurses) and Social Service professionals (Primary Care and community resources) are coordinated with the Nutritional Support Unit in the reference hospital in a collaborative manner. The first step has been to incorporate mandatory nutritional and social risk factors screenings in patients identified as CPCHN. A positive nutritional or social screening have been linked to comprehensive nutritional and social assessment plans that will allow diagnosing and encoding malnutrition and identifying patients at risk of social dysfunction. Diagnosis of DRM or social dysfunction is linked to an integrated intervention plan (nutritional and social), that includes case-conferences in the case of patients with complex needs. Highlights: Prior to the development of the strategy for dealing with DRM in CPCHN, a low implementation of nutritional screening was detected. This fact was probably due to a low awareness of DRM, but also for lack of a feasible and efficient plan of approach, that must include not only the health aspects but also the social determinants that accompany the disease. Contingencies: The implementation of this strategy is time-consuming, and requires an integrated health and social work. Tutorials have been attached to the shared medical history of Catalonia to guide professionals in the application of the screenings. Timeline: The prevalence study of DRM in the community has been finished at January 2016. The mandatory screening and the validation of the nutritional and social intervention plan will be implemented during 2016. Conclusion: The results of the prevalence study of DRM in CPCHN could be extrapolated to the rest of Catalonia, allowing us to manage effectively the health and social policies. It will also allow us to analyze the impact of different health care quality indicators linked to the strategy to approach to DRM. Nutritional and social community intervention can be cost - efficient, as demonstrated in the hospital setting, and probably will allow reducing unnecessary admissions, readmissions, complications, need for social resources and will help improve the quality of life in CPCHN. The impact of this strategy is based in detecting and treating in an integrated and collaborative manner DRM in CPCHN. [ABSTRACT FROM AUTHOR]

Palliative care (PC) has focused on patients with cancer within specialist services. However, around 75% of the population in middle-income and high-income countries die of one or more chronic advanced diseases. Early identification of such patients in need of PC becomes crucial. In this feature article we describe the initial steps of the NECPAL (Necesidades Paliativas [Palliative Needs]) Programme. The focus is on development of the NECPAL tool to identify patients in need of PC; preliminary results of the NECPAL prevalence study, which assessed prevalence of advanced chronically ill patients within the population and all socio-health settings of Osona; and initial implementation of the NECPAL Programme in the region. As first measures of the Programme, we present the NECPAL tool. The main differences from the British reference tools on which NECPAL is based are highlighted. The preliminary results of the prevalence study show that 1.45% of the total population and 7.71% of the population aged over 65 are 'surprise question' positive, while 1.33% and 7.00%, respectively, are NECPAL positive, and surprise question positive with at least one additional positive parameter. More than 50% suffer from geriatric pluri-pathology conditions or dementia. The pilot phase of the Programme consists of developing sectorised policies to improve PC in three districts of Catalonia. The first steps to design and implement a Programme to improve PC for patients with chronic conditions with a public health and population-based approach are to identify these patients and to assess their prevalence in the healthcare system. [ABSTRACT FROM AUTHOR]

Background: The implementation of Integrated Care poses many challenges at a macro, meso and micro level. This workshop aims to explore the role that a proven intervention like Integrated Care Pathways is playing in advancing cultural and organizational transformation towards integrated care. Worldwide there are a plethora of ICPs implementation initiatives offering a great opportunity for knowledge exchange and cross-boundaries learning, but the latest studies show a high degree of variability in the implementation of ICPs. Aims and Objectives: The Aim of this workshop is to offer the ICIC 2019 audience an opportunity to hear from the latest international advances on ICPs implementation and to reflect upon collectively. Specific objectives are: - To share the state-of-the-art evidence on ICPs - To present the latest analysis of ICPs implementation, variability, challenges and key learnings - To present key findings from a best practice intervention of ICPs implementation at a systemic level in Spain - To present key findings and understandings from an ICPs case study with cancer patients at a hospital in Ireland - To access an innovative example of ICPs technology-based implementation in cancer patients - To debate on the future role of research in ICPS as a technology to promote Integrated Care and inform practice - To inspire reflection on the crossroads between ICPs and Chronic Care, Population Health Management and healthcare prevention - To allow discussion on effective ways to engage patients participation in ICPs developments Format: The proposed format for the workshop consists of a 60 minutes session as part of the main conference stream. The workshop intends to be a step in the ongoing process of reflection on ICPs research, implementation improvement, performance analysis and patient engagement. Timings and speakers: 15 minutes. Massimiliano Panella (Italy). President of the European Pathway Association. Latest international evidence on ICPs implementation. 15 minutes. Carles Blay (Spain). Family Physician, ex-director of ICP strategy in Catalunya and Director of Medicine Faculty at Vic University. Key learnings from ICPs implementation in Spain 15 minutes. Ornela Bardhi (Albania). Marie Curie PhD Fellow at Cancer: Activating Technology for Connected Health. Understanding and mapping the Patient Journey in Cancer. 15 minutes. Open debate and conclusions. Coordinated by Elena Urizar, Deusto Business School Health. Target audience: Healthcare organization managers, policy makers, decision makers and implementation teams and researchers in the field of ICPs and integrated care. Learnings/Take away: The output of the roundtable will be relevant for informing research and practice on key aspects to improve ICPs implementation and on finding ways to include patient's participation in the development of ICPs. [ABSTRACT FROM AUTHOR]

Introduction: ICPs are a proven intervention to advance Integrated Care. However their implementation poses great challenges, among others, it needs alignment from micro, meso and macro management and the deployment of change management strategies. Description: The Center for Innovation and Change Management is playing a facilitating role in the Spanish NHS, supporting the implementation of ICPs in different regions, with a systemic perspective, through the generation of new knowledge, innovative change management strategies and the dissemination of good practices. Change: Based on Kaiser Permanent, Chronic Care Model, Berwick's Quadruple Aim for IC, population health management, and Kotter's Change Management Model. Population: The activities of the Center are addressed to supporting the work of decision makers, managers and multidisciplinary clinical teams who can drive the implementation of ICPs, in different organizations such as individual healthcare organizations, integrated care systems up a full Regional Health System. Timeline: Since January 2017 the Center has supported the structured implementation of ICPs Highlights: The Center has developed and validated with a multilevel group of experts two main toolkits, a Design and Implementation Guide and a Checklist to support the implementation of ICPs. In parallel, it has designed and developed a series of thematic workshops on integrated care, change management, teamwork, and leadership. The Center has reached out to more than 700 key implementers and offered training to over 100 decision makers, managers, and clinicians. The greatest achievements were reached in Comunidad Valenciana regional health system, where ICPs have been adopted by the Regional Health Authority as the blueprint for transformation, and have been included as a KPI on the commissioning agreements. In total, 8 ICPs have been implemented in the following diseases: Stroke, Diabetes, Coronary System, Agitated Patient, Asthma and Dyspepsia. Sustainability: It is too early to assess the sustainability of these strategies, however, it seems plausible to expect a high degree of long-term sustainability when this work is embedded in other management and governance tools, such as strategic plans, performance agreements, commissioning plans. Transferability: The SNS is decentralized in 17 regional systems with Chronic Disease Management strategies in place, facilitating the piloting and implementation of initiatives and offering an opportunity for cross-learning and knowledge exchange. The toolkits created have been developed by a multilevel group of experts, leaders of the main regions, and this, allows the proposed guidelines to have maximum applicability. Conclusions: - Facilitators are useful in accelerating the deployment of ICPs - Successful implementation requires the buy-in of the top leadership and alignment - Contextualization, transparency, and involvement from start are key for clinicians buy-in Discussion: successful ICP implementation requires a deep understanding of the local context and alignment between bottom-up and top-down. However in a NHS systems like the SNS bottom-up initiatives are often difficult to scale up and it is necessary to encourage change and alignment at the meso and macro level and top leadership support. Lessons: Where there is a methodology, change management training, facilitation and follow-up actions, deployment is faster and smoother. [ABSTRACT FROM AUTHOR]

Introduction: Integrated Care Pathways are a proven effective intervention to improve care coordination and quality of care, however their effective implementation presents important challenges and barriers at the clinical, meso and macro level. There is ample literature on actions and elements to be considered to ensure the success in the implementation of the ICPs, however they have not been ordered or systematized. This work develops a checklist to be applied in the implementation of ICPS with a systemic perspective, contemplating the actions to be developed at the macro, meso and micro levels. Theory: Checklists are an algorithmic listing of actions to be performed in a specific setting, to ensure that no step will be forgotten. Although a seemingly simple intervention, checklists have a sound theoretical basis in principles of human factors engineering and have been successfully applied in the health sector. On first place a checklist tool was created to support the implementation of ICPs based on a literature review, previous experiences on ICPs implementation in the Spanish contexts and a consensus by the core research team. Secondly, a multidisciplinary group of key opinion leaders 19, including practitioners, healthcare managers and policy makers from 9 Spanish regions validated and improved the tool for its successful application on a real setting. An individual reflection was followed by a moderated group discussion. Three aspects were evaluated: the validity of the proposed structure and approach, the utility of the checklist for the different and the content of the phases and items including proposals for improvement. Results: The tool has been created as a checklist comprising 25 items grouped in the following 7 phases: health policies, organizational readiness, awareness, leadership alignment, local deployment, support and evaluation & improvement. The final validated and improved version of the checklist including the 25 items will be presented at ICIC18. Discussions: The developed checklist has a high face-validity for more than 20 integrated care experts of different Spanish healthcare subsystems that consider it as a useful tool to help implementers to follow on a quick and simply way what things need to happen to successfully implement ICPs in a local context. However the checklist has still to be tested in real policy and practice. Conclusions: A checklist for guiding ICP implementation has been developed and validated for the context of the spanish health system that seems useful for other kind of systems but particularly in those NHS-like and with dominant public provision. Lessons: The application of checklists in healthcare management is possible and accepted by managers, although the approach cannot seem as mechanistic as in more structured, simple and sequential kind of interventions. Limitations: By standardizing the list of steps to be followed, and formalizing the expectation that every step will be followed this checklist has the potential to greatly minimize failures; however ICP implementation is a complex intervention where other complementary tools and change management approaches are required to ensure success. Suggestions: It would be recommended to pilot this checklist in different healthcare organisations and contexts. [ABSTRACT FROM AUTHOR]

Introduction: Integrated Care Pathways are a proven effective intervention to improve care coordination and quality of care, however their implementation presents important challenges and barriers at the clinical, meso and macro level. The literature identifies actions and elements to be considered that contribute to their effective implementation. However, their implementation is context-dependent, needing a systemic perspective to understand the barriers and elements that can facilitate its deployment in the Spanish National Health System. Theory: We understand ICPs as a pact between professionals and organizations from different healthcare areas that operate in the same territory and serve the same population affected by a specific health problem/s, to apply the criteria of good practice, optimize care circuits and plan responses to foreseeable scenarios. A qualitative research session was conducted with a multidisciplinary group of key opinion leaders 19, including clinicians, healthcare managers and policy makers from 9 different Spanish regions. Design thinking methodology was used to identify and agree upon key barriers and enablers for the implementation of ICPs from a macro, meso and micro perspective. The session was underpinned, by the knowledge gathered through systematic review and lessons learned from a best practice of ICPs implementation in Spain. Results: Structured list of key barriers and enablers at macro, meso and micro level for an effective implementation of ICPs. The identified barriers were: lack of systemic and integrative vision; clinical and social complexity of the patient, rigidity and work in silos, nonintegrated information systems; individualist professional culture, absence of transformational leadership, patient not located in the center, and lack of training. Enablers were also identified. Discussions: As the literature highlights, successful ICP implementation requires a deep understanding of the local contexts and alignment between bottom-up initiatives and topdown support. Conclusions: There are several issues preventing a larger deployment of ICPs in Spain: at macro level there is a general lack of strategic vision towards integrated care from a systems perspective, especially from a multisector approach. At meso level, the historical fragmentation of organizations poses a strong challenge towards care coordination. At the micro level a lack of clinical leadership and buy-in hinders the needed multidisciplinary and collaborative work. Strategic alignment, better information systems, improving data collection, continuous monitoring and evaluation, feedback looping to professionals, incentives and training healthcare professionals in communication and team-work skills were identified as facilitators. Lessons: Although coming from different regions and professional backgrounds, all participants have experienced similar problems with the implementation of ICPs. ICPs implementation go beyond the development of a booklet with a set of guidelines, they imply local agreements, cultural change and doing things differently. They need a strong sustained buy-in from every level, a leading core team, sufficient resources, and a continuous support to manage cultural change and adaptation to local context. Limitations: This research has been focused on a particular health system. Conclusions should be generalized with caution. Suggestions: Further research is needed to demonstrate if the conclusions of this study are applicable to other settings, particularly in non NHS-like systems. [ABSTRACT FROM AUTHOR]

The Ministry of Health (MH) of Catalonia promotes the formal implementation of a new model of integrated care, comprehensive and person-centred, from a community and populationbased approach, and primarily addressed to those who have social or health complex needs. All systematic focus groups conducted by MH about implementing strategies emphasize continuing education as a key element of success, especially when it is carried out in a massive manner and it's approachable to all the professional profiles related to public integrative policies. Moreover, the Catalan Society of Family and Community Medicine (CAMFiC) has a long tradition in an online learning problem-based program called CAAPS (Course Self-related in Primary Health Care) in which, from pre-established learning objectives, several scenarios based on significant community clinical cases are developed, chosen because of their prevalence or difficulty. In CAAPS, family physicians with the support of experts from other disciplines produce a series of e-textbooks and monographs that gather these scenarios, and compile the evidence and best practices related with. Finally, after reading the books, additional material to assess the progress of learning is provided to learners. In this context, the MH and CAPPS' editorial committee agreed the publication of two books about caring flail, chronic complex and advanced patients, according to the Catalan governmental model of integrated care. This material has been prepared in 2014 by three family physicians, with the co-operation of 18 expert reviewers, from several specialties and professions, from social and health services. The books were accompanied by several additional educational tools: - Training of trainers in every health care centre, transferring material to carry out standardized formative sessions - Multimedia website where trainers can access to supplemental pedagogic material - Open access to CAPPS notebooks funded by the Ministry of Health for people not subscribed to formal on-line version. - Supportive website to CAPPS-based learning where tutors answer students questions. This training package has been widely spread, addressing it to all professional profiles working at the community level (family physicians, community nurses, case managers and social workers). At present, the results of this educational action are: - People formally subscribed to the CAAPS 1005 registered. Notebook 1: 330 exams done; 313 approved. Notebook 2: 252 exams done; 250 approved - Session of Training of Trainers: 305 students with a degree of satisfaction with the activity average of 4.5 out of 5 - Sessions at health centres, perform up to 31 January, 2016, 96 carried out, 11 scheduled - Access to the web material support: 1248 different people have accessed the website and 324 have viewed the videos. - Enrolled in the Ministry funded version, to perform from November 2015 to February 2016: 3132 registered (1851 Barcelona, 377 Girona, 193 Lleida, 431 Tarragona) 556 men and 2576 women, 1594 nurses, 1344 doctors, 65 social workers. In terms of coverage, these results imply that this training proposal reaches 100% of territory and community teams, virtually 100% of clinical leaders and healthcare mentors and that 25% of primary care professionals have been exposed to it, allowing a) sharing terminology and a common vision on integrated care for complex needs, b) knowing the conceptual basis of this model of care and c) providing tools for managing most common clinical situations that arise in day-to-day care of complex patients. Currently we are designing the method to assess the impact of this educational strategy on professional performance. Conclusions: Training is a key element for the dissemination of integrated care on chronic complex conditions. The co-operation between government and scientific societies can be crucial to achieve high impacts in educational coverage. This synergistic action multiplies results and facilitates training to all territories and all stakeholders. [ABSTRACT FROM AUTHOR]

Background: Care models for advanced chronic patients present two key aspects: early identification and advanced care planning (ACP). In 2014, Catalonia arranged the ACP Model (ACPM), addressed to chronic patient's complex needs, into a public health-social system (HSS). Aims: Describe the implementation process (IP) of an ACPM. Methods: A core group of professionals (n=55) was convened to develop the ACPM with the co-participation of patients, caregivers, social agents and healthy persons. Inclusion criteria included: solid professional trajectory, equal representation as for territory and professional profile. Four work levels were defined: conceptual document (CD) and implementation guide (IG) elaboration; training program (ITP) development; building-up of patients, professionals and healthy persons discussion groups (DG). The CD and IG were written with the agreement of expert professionals in legislation, ethics, medical specialities, nursing, anthropology, social work and psychology. The ITP is being created, as a key aspect of the IP. Results: CD and IG have been published. Simultaneously, DGs are established so as to make the CD a work product of high quality. The ITP is currently being developed, based on CD and IG contents. These documents have been reviewed by around 100 professionals from the Catalan HSS. The ITP contents focus on communication skills; legal and ethical aspects; patient and family needs. Discussion: ACP is a challenge for the model of care towards advanced chronic patients. Conclusions: ACP is a challenge for the model of care towards advanced chronic patients. The Catalan Model of ACP establishes the conceptual and pragmatic foundations of ACP and develops the training of the professionals daily taking care of such type of patients. [ABSTRACT FROM AUTHOR]

Background: The Surprise Question (SQ) identifies patients with palliative care needs. The NECPAL CCOMS-ICO © (NECPAL) tool combines the Surprise Question with additional clinical parameters for a more comprehensive assessment. The capacity of these screening tools to predict mortality is still unknown., Aim: To explore the predictive validity of the NECPAL and SQ to determine 12- to 24-month mortality., Design: Longitudinal, prospective and observational cohort study., Setting/participants: Three primary care centres, one general hospital, one intermediate care centre, and four nursing homes. Population cohort with advanced chronic conditions and limited life prognosis. Patients were classified according to SQ and NECPAL criteria and followed for 24 months., Results: Data available to assess 1059 of 1064 recruited patients (99.6%) at 12 and 24 months: 837 patients were SQ+ and 780 were NECPAL+. Mortality rates at 24 months were as follows: 44.6% (SQ+) versus 15.8% (SQ-) and 45.8% (NECPAL+) versus 18.3% (NECPAL-) ( p = 0.000). SQ+ and NECPAL+ identification was significantly correlated with 24-month mortality risk (hazard ratios: 2.719 and 2.398, respectively). Both tools were highly sensitive (91.4, CI: 88.7-94.1 and 87.5, CI: 84.3-90.7) with high negative predictive values (84.2, CI: 79.4-89.0 and 81.7, CI: 77.2-86.2), with low specificity and positive predictive value. The prognostic accuracy of SQ and NECPAL was 52.9% and 55.2%, respectively. The predictive validity was slightly better for NECPAL., Conclusion: SQ and NECPAL are valuable screening instruments to identify patients with limited life prognosis who may require palliative care. More research is needed to increase its prognostic utility in combination with other parameters.

Introduction: The Chronicity Prevention and Care Programme set up by the Health Plan for Catalonia 2011-2015 has been an outstanding and excellent opportunity to create a new integrated care model in Catalonia. People with chronic conditions require major changes and transformation within the current health and social system. The new and gradual context of ageing, increase in the number of chronic diseases and the current fragmented system requires this transformation to be implemented., Method: The Chronicity Prevention and Care Programme aims to implement actions which drive the current system towards a new scenario where organisations and professionals must work collaboratively. New tools should facilitate this new context- or work-like integrated health information systems, an integrative financing and commissioning scheme and provide a new approach to virtual care by substituting traditional face-to-face care with transfer and shared responsibilities between patients, citizens and health care professionals., Results: It has been observed some impact reducing the rate of emergency admissions and readmission related to chronic conditions and better outcome related to better chronic disease control. Some initiative like the Catalan Expert Patient Program has obtained good results and an appropriate service utilization., Discussion: The implementation of a Chronic Care Program show good results but it is expected that the new integrated health and social care agenda could provoke a real change and transformation. Some of the results related to better health outcomes and a decrease in avoidable hospital admissions related to chronic conditions confirm we are on the right track to make our health and social system more sustainable for the decades to come.

Purpose of Review: We describe conceptual innovations in palliative care epidemiology and the methods to identify patients in need of palliative care, in all settings.In middle-high-income countries, more than 75% of the population will die from chronic progressive diseases. Around 1.2-1.4% of such populations suffer from chronic advanced conditions, with limited life expectancy. Clinical status deteriorates progressively with frequent crises of needs, high social impact, and high use of costly healthcare resources., Recent Findings: The innovative concept of patients with advanced chronic diseases and limited life prognosis has been addressed recently, and several methods to identify them have been developed., Summary: The challenges are to promote early and shared interventions, extended to all patients in need, in all settings of the social care and healthcare systems; to design and develop Palliative Care Programmes with a Public Health perspective. The first action is to identify, using the appropriate tools early in the clinical evolution of the disease, all patients in need of palliative care in all settings of care, especially in primary care services, nursing homes, and healthcare services responsible for care provision for these patients; to promote appropriate care in patients with advanced diseases with prognosis of poor survival.