Marc Bruijnzeels directeur 26-07-10 Tracking en Tracing Marc Bruijnzeels directeur 1

Grote probleem 26-07-10

Oplossing: Tangram 26-07-10

Oplossingsrichting: populatie gerichte zorg en welzijnsorganisaties Mens gericht Populatie oriëntatie Veelomvattend Coördinatie Laagdrempelig poortwachter Bron: B. Starfield 2010

Herinnert u zich deze nog? 26-07-10

1. Populatiemanagement Eerste lijn Tweede lijn 26-07-10 26-07-10 6 6 DM2 CVRM ? 6 6

Voorkomen van meerdere ziekten bij > 55 jaar Oostrom, S.H. van, Picavet, H.S.J., Gelder, B.M. van, Lemmens, L.C., Hoeymans, N., Verheij, R.A., Schellevis, F.G., Baan, C.A. Multimorbiditeit en comorbiditeit in de Nederlandse bevolking: gegevens van huisartsenpraktijken. Nederlands Tijdschrift voor Geneeskunde: 2011, 155(A3193)

Overlap tussen 65-plussers met multimorbiditeit, beperkingen en kwetsbaarheid 12 Kwetsbaarheid 2 Beperkingen 4 52 8 2 13 7

Definities populatiemanagement The coordination of care delivery across a population to improve clinical and financial outcomes, through disease management, case management and demand management (McGraw Hill 2002) “the technical field of endeavor which utilizes a variety of individual, organizational and cultural interventions to help improve the morbidity patterns (i.e., the illness and injury burden) and the health care use behavior of defined populations”. (Hillman 2008)

Kenmerken PHM PHM is distinguished from disease management by including more chronic conditions and diseases, by use of "a single point of contact and coordination," and by "predictive modeling across multiple clinical conditions". PHM is considered broader than disease management in that it also includes "intensive care management for individuals at the highest level of risk" and "personal health management... for those at lower levels of predicted health risk."

De wijk is niet de praktijk 26-07-10 De wijk is niet de praktijk De patiënten zijn niet gemiddeld qua zorgvraag 11 11

Risicopiramide Casemanagement Diseasemanagement Zelfmanagement 9-12-2011

26-07-10

Total panel ownership Total Panel Ownership represents a population-based approach to care in which self-governing teams of primary care providers develop and execute proactive plans to address gaps in care for a defined panel of patients during office visits and through follow up services and outreach. Several information technology–based tools support the teams by highlighting discrepancies between recommended and actual care and providing timely feedback on performance. 26-07-10

26-07-10

Panel management panel management as a set of tools and processes for population care that are applied systematically at the level of a primary care panel, with PCPs directing proactive care for their empaneled patients. Neuwirth et al 2007. The Permanaente Journal

Features of Panel management Two features distinguish panel management: processes to identify and address unmet care needs are more tightly linked with primary care practices and less-intense, individualized outreach and follow-up are provided for more patients via telephone contact with panel management assistants 26-07-10

26-07-10

Effectief? Savings: $ 63 PMPM overall $ 115 PMPM for 65+ Wise et al. Dis Man 2008

“Must Pass” element NCQA for Patient Centered Medical Homes The practice tracks, follows-up and coordinates tests, referrals and care at other facilities (e.g. hospitals) The practice manages care transitions 26-07-10

Voorbeelden van tracking en tracing 26-07-10

26-07-10

Tracking en tracing in de zorg Systematische opsporing en follow up van chronische zorg patienten (DM2, COPD, CVRM) Screeningsprogramma’s (BMHK, borstkanker) Ouderenzorgprojecten 26-07-10

Stichting Mondriaan Health Research Data Doel: een nationaal toegangsloket tot bestaande en nieuwe bronnen van gezondheids(zorg)gegevens voor wetenschappelijk (pharmaco-) epidemiologisch onderzoek. Meer speciek: Nationale infrastructuure en toegangspunt Koppelen, poolen, verrijken van bestaande en nieuwe gezondheids(zorg)- data

Mondriaan at a glance: Cohort Partnership with major Dutch data suppliers High quality ICT infrastructure Privacy Record linkage data-’esperanto’ data researcher Mondriaan info data Let’s think of Mondriaan as a nerve cell: Connetion with other parties, state of the art infrastructure, integration of data and delivery of data to other parties ICT infrastructure: privacy, data-extraction, exports, linkage, catalogue Automatic & validated Record linkage increase sample size Enrichment of data on patient level (e.g.: GP (e.g. ZGA), pharmacy, hospital admission/ discharge data (through individual hospitals or through PHARMO/String of Pearls Initiative), laboratory medicine, genetic data, imaging findings, biomaterials,etc. Strong emphasis on privacy of patient and health care professional. Anonymisation through >10 Privacy Enhancing Techniques: TTP, triple pseudonimisation, external, independent review of data-requests, etc Only scientifically valid and relevant research will be supported (independent review) 5. Record linkage Increase sample size Enrichment of data on patient level Cohort Claims

organisations in and outside NL HDR concept Information products Authorities: RIVM, etc. HIS KIS De zorgverlener plaatst vanuit zijn XIS een export in de HDS. Dit kan een volledige kopie zijn van de eigen data, maar dat hoeft niet. In de praktijk zal de zorgverlener zich laten leiden door gemak (hoe eenvoudig is het om data te exporteren) en door het eigen belang (welke data zijn nodig voor de rapportages worden m.n. op de eigen data gebaseerd, maar kunnen ook op basis van gekoppelde data plaatsvinden binnen de HDS. Uitlevering van data naar andere partijen (zoals wetenschappers en beleidsmakers) is mogelijk, maar vereist een besluit door een locale commissie ZIS Local review of requests for data Univer- sities City/region AIS Other research organisations in and outside NL Organise the collection of data and reports close to the data source 26 26

Voorbeelden dichter bij huis Verwijskaart (DOH) Nabellen van verwezen patiënten (Arts en Zorg) Care gap analyse (Stadsmaatschap) ……………. 26-07-10