Longevity and Chronicity

Health systems can be considered direct variants of social systems, they are complex, open and interrelated systems, with determinants of other systems, such as the political, fiscal and educational systems (Cabo-Salvador, Cabo J, & Iglesias, 2010; Cabo-Salvador, Bellmont, Cabo J, & Herreros, 2010). In order to be considered as systems, according to the World Health Organization [WHO], it must: Be universal, that is, provide coverage to the entire population; have comprehensive care, both hygiene and mental health, as preventive medicine, primary care, specialized assistance in all acute and chronic diseases; be equitable in the distribution of resources; be efficient, that is, provide the best benefits and the best level of health at the lowest cost; be flexible, to be able to adapt and respond quickly to new needs; and count on the participation of citizens in its planning and management (Cabo-Salvador & Bellmont, 2014).

It is urgent to face the current challenges of health care. Thus, the impact of the aging of the population, the need to incorporate therapeutic innovations in clinical therapy (Real Decreto-Ley 16/2012) and the development of personalized medicine and regenerative medicine are going to suppose, undoubtedly, an increase in health expenditure (HSCIC, 2015; Busse, Blümel, Scheller-Kreinsen, & Zentner, 2009; Cabo-Salvador et al., 2014; Cabo-Salvador, Bellmont, Herreros, & Cabo J, 2014; Curtis , 2012). Therefore, reforms and new forms of management are needed to strengthen sustainability, improve efficiency and introduce new models and management tools with coordination of socio-health services (Barr, et al. 2003; Boult, Kane, Pacala, & Wagner, 1999; Cabo-Salvador, de-Castro, Cabo, Ramos, & López, 2017; Cabo-Salvador, Ramírez, Cabo, Ramos, & de-Castro, 2018; Coleman, Austin, Brach, & Wagner, 2009; Sylvia et al., 2008; Weiss, 2007; Wagner, 1998; WHO, 2002; Zwar et al., 2006).

Currently, having into account a greater longevity and life expectancy of the population, as well as an increase in the number of people over 60 years of age, the increase in chronic pathologies has meant an increase in healthcare costs in a global manner. According to United Nations prospective studies (2017), the percentage of people over 60 years of age will increase from 10% of the population in 2000 to 21% of the population in 2050 (Beaglehole et al., 2008; Bodenheimer & Berry-Millett, 2009; Cabo-Salvador, 2017; Gilmer et al., 2006; MacAdam, 2008; WHO, 2002; UN, 2017). According to the latest data published and contrasted in 2018, health spending as a proportion of GDP reached the average figure of 9.5% in the OECD countries (OECD, 2017), as shown in Figure 1.

Figure 1.
Health expenditure as a % of GDP in OECD countries

Due to the increase in longevity and life expectancy, the number of people with multiple pathologies that demand attention to their character of chronicity is continuously increasing, which is why it is a real priority in health policies, due to its high prevalence and the significant economic repercussion, and the greater use of health services that it implies. It is estimated an attention to chronic processes between 70% and 75% of total health expenditure in industrialized countries (Cabo-Salvador et al., 2010; Goodwin & Curry, 2008; Hroscikoski et al., 2006; Ouwens, Wollersheim, Hermens, Hulscher, & Grol, 2005; Ramsey et al., 2008; WHO, 2002). This attention to chronic patients implies an imperative need to change the paradigm of the current management model, from fragmented and isolated care, social or health care, to a socio-health care integration; redesigning the organization and optimizing socio-health resources; enhancing primary care; reorganizing hospital management, focusing on acute care; transferring the management of chronicity to the family and community environment, with a greater, more efficient and higher quality social-health care integration perceived by the user (Arshad, Oxley, Watts, Davenport, & Sermin, 2000; Bengoa & Nuño, 2008; Boult et al., 2008; Cabo-Salvador et al., 2014; Cabo-Salvador et al., 2017; Cabo-Salvador, 2017).

In recent years, due to the economic crisis –which entails scarcity of resources–, the increase in longevity –with an increase in patients with chronic diseases with high costs–, and the introduction of new technologies, they have been carried out in different countries, several attempts to order and prioritize health services, given that the available resources are limited and that investing more resources in one sector implies investing fewer resources in another (opportunity cost), to ensure the provision of the most important services. Today, the world health expenditure is about US $ 5.5 billion per year and within that expenditure, historically the largest item corresponds to the hospital sector (hospital and specialized services) with approximately 54.2% of the total, followed by expenses in pharmacy with 21.5%. In a global way, hospitals consume the highest percentage of the health budget and that is why the practical application of the new integrated model of socio-health resources management can not only improve efficiency but also help in sustaining health systems. Improving the efficiency and degree of use of resources in health systems (expenditure control) and improving the quality of care (morbidity and mortality reduction) and achieving a high degree of satisfaction on the part of citizens should be the main objectives of health officials from both public and private institutions (Cabo-Salvador & Unda, 2010; Cabo-Salvador, Bellmont, Cabo J, & Cabo V, 2014; Gravelle et al., 2007; Gonseth, Guallar-Castillón, Banegas, & Rodríguez-Artalejo, 2004; Kane, Keckhafer, & Robst, 2002; Kane, Keckhafer, Flood, Bershadsky, & Siadaty, 2003; NPHS, 2006; Norris et al., 2002; WHO, 2002).

The confluence of technology-based products, platforms and applications in the health sector and solutions with intelligent cognitive systems, together with a more proactive culture of citizens, great accessibility and the ability to transmit and manage information and data - structured and unstructured-, they enable and offer, from the big hospitals, the medicalized residences or the same homes at the individual and family level, great possibilities of improvement in the health care, in the prevention of diseases, in the social and health management and in the management of chronic patients, and they are directed towards a medicine of great precision, previously unmatched (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017; de-Castro, Cabo- Salvador, Ramírez, & Garcia, 2014; Epping-Jordan, Pruitt, Bengoa, & Wagner, 2004; Evercare, n.d; López, de la Torre, Herreros, & Cabo-Salvador, 2014; Nolte & McKee, 2008; Ramos, Soguero, Mora, Rojo, & Cabo-Salvador, 2014; Rosen & Ham, 2008; Sevick et al., 2007; Singh, 2005; Wolff et al., 2009).

Telemedicine and uHealth

Artificial Intelligence [AI], long seen as promising in the health care sector, is already a reality. The explosion of Big Data, combined with the increase in the demand for care, originated due to the increase in the number of elderly people with chronic diseases; the costs increase and the shortage of available professionals to meet that demand; and the scarcity in number and geographical availability of access to reach all the population in need, have created a demand for services not covered by the existing offer, which can only be solved by this new technology. In the last years we are experiencing a great progress of the AI, that already began to cover, in an incipient way, this existing real demand. The economic and social advantages that can be achieved by integrating AI into the health sector are indisputable and unstoppable. In fact, new, more proactive health care models based on these technologies are emerging (Boult, Kane, & Brown, 2000; Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017; Herreros & Cabo-Salvador, 2014; López et al., 2014; Ramos et al., 2014).

With the development of AI and Big Data, we can today make medical diagnoses, better and faster and more accurate, and more effective treatments, and thus improve the quality and efficiency of health care in a more comprehensive manner, providing access to the health care system of quality and affordable health care with good results, to a large part of the population in need, all without the need for hospital healthcare resources (Cabo-Salvador et al., 2017; Cabo-Salvador et al. al., 2018; Cabo-Salvador, 2017). Although health care is still personal -and we do not want to lose human contact-, we will have to redefine the role of different professionals in the different healthcare processes and ensure that these new skills and teachings, which are already a reality and are part of daily medical assistance, can be incorporated into medical schools.

In the field of AI, we are living a spectacular breakthrough from both, the computational intelligence and Environmental Intelligence [EI] or ubiquitous computing, where the medical community is pioneering the early adoption of cognitive computing technology, thanks to its great capacity for analysis and interpretation and evaluation of data, a fundamental part in the management of chronic pluripathologic patients (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017; Fussell, 2006; Hébert et al., 2009; Kreindler, 2008; Morgan, Zamora, & Hindmarsh, 2007; Oeseburg, Wynia, Middel, & Reijneveld, 2009; Ollero, 2002; OPIMEC, 2018; Pearson et al., 2005; Russell, Thille, Hogg, & Lemelin, 2005; Tracy, Dantas, Moineddin, & Upshur, 2003; Vickers, Kramer, & Baker, 2006).

The center of this revolution includes the mass production and the widespread use of technologies derived from the development of digital logic circuits that use binary codes [bits], such as digital computers, smartphones and tablets. The architecture of the information systems is one of the key points in the design of the Electronic Medical Record [EMR], with the purpose that they serve, not only for registration and data storage, but for purposes of clinical management considering the interrelation between the central database [Data Warehouse], under the skeleton of the conventional clinical history, nourished on the basis of the Minimum Basic Data Set [MBDS] extracted from the care process. The great technological advances, together with wireless connectivity, currently through Wi-Fi and in the immediate future through Li-Fi [light fidelity]. All of the above integrated through mobile devices, with Android or iOS operating systems, have created a great accessibility to health care. Therefore, citizens can take proactive care of their health and get a better real information about their health status, as well as make decisions based on that information and in direct collaboration or via online with the different health providers, all aimed at personalized medicine (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017; de-Castro, Cabo-Salvador, Ramírez, & Garcia, 2014; López et al., 2014; Ramos et al., 2014; Weiss, 2007).

The u-Health [ubiquitous telemedicine] and the Information and Communication Technologies [ICT] in health, in its different modalities of teleconsultation, remote diagnosis, telemonitoring, telecare, telesurgery, teletraining and telerehabilitation, are defined as the use of information and ICTs as support for clinical care, health education and public health at a distance.

The u-Health (Figure 2) is a variant of telemedicine performed with the support of mobile devices and environmental sensors (environmental intelligence). ICTs are the engine of change in the management processes of chronic patients, usually multi-pathological (chronic patients of great complexity and comorbidity who require comprehensive management with professional care, chronic patients with high risk but less complexity, combining self-management and professional care) and the strengthening of the socio-sanitary interface in an environment such as the current one, in which there is a health model focused on the care and treatment of acute patients (Cabo-Salvador et al, 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017; de-Castro et al., 2014; López et al., 2014, Ramos et al., 2014).

Figure 2.
uHealth. Hospital without barriers. Personalized Medicine

The impact of ICT is decisive in the development of medicine and key in the management of chronic patients, since it improves the quality of care and safety. It also changes the concept of equity and accessibility, by overcoming geographical, political, economic, and administrative barriers, as well as helping to improve the continuity of the care process based on efficiency, effectiveness and effectiveness, reducing costs, avoiding duplication of tests, streamlining processes, avoiding the development of morbidities, and enabling the development of personalized medicine. By offering computer services through a network, generally Internet, the adoption of cloud computing technologies has further boosted the implementation of telemedicine and Electronic Medical Records [EMR] in our healthcare environment (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017; Clark Jr., Snyder, Meek, Stutz, & Parkin, 2001; Drennan & Goodman, 2004; MedPAC, 2007; Sheaff et al., 2009; Sylvia et al., 2006; John Hopkins University, 2010; Tinetti, Bogardus, & Agostini, 2004).

The increase in both longevity and chronic pathologies, implies an increase in the demand for healthcare services, which implies an increase for resources need, both structural and material, as well as human, and an opportunity for telemedicine and telecare, both for remote diagnoses (telehealth: Telecardiology, teleophthalmology, teledermatology), and for remote monitoring of assisted patients, not only in Intensive Surveillance Units [ISUs], Intensive Care Units [ICUs], Reanimation Units [RUs] and hospitals emergency boxes, but also in outpatient health and para-healthcare centers, such as pharmacies or local rural support centers; as well as medicalized residences and private homes (home health care). The above, through the development and application of vital signs detection systems, the use of nanotechnology and Environmental Intelligence [EI] and its transmission through interactive screens, smartphones and tablets (iPad), with the development of EMR [Electronic Medical Records] for preventive diagnostic tests (Barr et al., 2003; Boult et al., 1999; Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017; de-Castro et al., 2014; López et al., 2014; NPHS, 2006; Nolte & McKee, 2008; Oeseburg et al., 2009; Ovretveit & Staines, 2007; Parchman, Zeber, Romero, & Pugh, 2007; Parchman & Kaissi, 2009; Shojania et al., 2006; Sperl-Hillen, 2004; Wagner et al., 2001; Wagner, Davis, Schaefer, Von-Korff, & Austin, 1999).

Definitely, ICT, in addition to improving the quality of care, play an important role in patient safety and lead to savings in the consumption of healthcare resources (avoiding duplicities in diagnostic tests), with a reduction in medical errors, avoiding morbidities associated with inappropriate treatments and improving care through an Evidence-Based Medicine [EBM]. ICTs will play a very important role in health organizations with the aim to improve the quality, efficacy and efficiency of health services, as strategic management tools, which are keys to increase accessibility and equity. They also optimize administrative processes, through the improvement of the care continuity, the enhancement of interoperability between the different healthcare centers, giving support in Homecare and managing chronic patients. The above by improving the efficiency and sustainability of health systems and increasing the quality and safety of care, and also helping to make clinical and management decisions (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017; Drennan & Goodman, 2004; Kreindler, 2008).

ICTs are the change engine in the management processes of chronic patients, generally multi-pathological. On the other hand, they are the strengthening of the socio-health care interface, in an environment such as the current one, in which there is a health model focused on the care and treatment of acute patients. We are currently in a change of paradigm of the health model, change of the absolutely necessary assistance model that is heading for a restructuring of the assistance services concerning a management by processes, matrix, and towards a disease management, Therefore, it implies an organizational change in which coordination is essential at a social and health level. Understanding the above as an integrated model with real interoperability between primary and specialized care, mainly a patient-centered model that encourages self-care and co-responsibility to manage your chronic situation. The potential of uHealth lies in the possibility of interacting directly, even online, with professionals in the health sector, which allows us to manage our own health through the Internet, with the support of ICT, converging with current technological trends, such as iCloud, a cloud computing storage system (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017; de-Castro et al., 2014; López et al., 2014; Ramos et al., 2014).

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uHealth and ICT in Chronic Patients

UHealth, nanotechnology and Environmental Intelligence allow us to know the patient’s biomedical status in their usual environment everyday life as well as offer all the diagnostic information of interest for both, the primary care physician and the specialist. Hence, it allows us to draw a “Hospital without barriers” scenario, virtually located in the patient’s environment (Home Care). In these scenarios, the patient is surrounded by multiple autonomous sensors that form ad hoc networks, such as BAN [Body Area Networks], PAN [Personal Area Networks] or HAN [Home Area Networks], which acquire the information of interest: From scales or portable tensiometers, up to mobile electrocardiogram monitors, automatic defibrillators and devices that can be implanted in the skin or tissues, through environmental temperature, humidity and position sensors, etc. (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017; de Castro et al., 2014; López et al., 2014; Ramos et al., 2014).

Currently, telemedicine medical applications are mainly focused on the patient, but the role of health professionals in this environment should not be forgotten: Doctors, caregivers, pharmacies and pharmaceutical laboratories, which are often the forgotten of the system. Achieving synergy among all actors, and focusing on patients, are the main challenges faced by the current and the future telemedicine.

The Environmental Intelligence [EI] is a concept that currently arouses much interest due to a new conception of the use of computers within a habitable environment. The implementation of this technology implies a further step in the mode of interaction between the user and the machines. The emerging concept of EI offers the possibility that in everyday environment (home, moving on the street, in transport, in public places, in hospitals, etc.) the user can have integrated intelligence that facilitates daily life. The EI is not a prediction of the future, but a vision. EI refers to the future of the information and communications society as a consequence of the convergence of ubiquitous communication and easy-to-use interfaces (Cabo-Salvador, 2017; de Castro et al., 2014).

EI-based systems produce intuitive and intelligent interfaces, which are included in everyday objects and environments (furniture, clothing, vehicles, roads and even in paint or tissue particles), capable of detecting human presence and their needs, which respond to discontinuous, discrete and are often invisible. Ubiquity, transparency and intelligence are the three basic properties of intelligent environments: ubiquity to find them at the point where the user is; transparency to go unnoticed in the physical environment; and intelligence to get an adaptation to the preferences of each individual. Autonomous power capacity is one of the most significant aspects of the devices. Therefore, we have to find efficient methodologies, that is, materials and systems that can maximize the energy and minimize the consumption of the emission-reception units (Cabo-Salvador, 2017; de Castro et al., 2014).

In EI environments, ICT-based devices and computers “blur” at the bottom of them, while individuals are surrounded by intelligent and intuitive interfaces integrated into all types of objects. The environment recognizes individuals and some of their desires and needs, as well as the change of their own environment. EI would respond without discontinuity, discreetly and sometimes invisible, but always under human control.

There would be intelligent agents with the power of making decisions or carrying out some action (de Castro et al., 2014).

The EI offers the possibility of having integrated intelligence that facilitates process and matrix management, in all day-to-day environments. The concept of EI is a frontier terrain between the latest advances in ubiquitous computing and the new concepts of intelligent interaction between user and machine. In the real field, EI consists of the interaction of a series of everyday objects with “soft” and non-intrusive interactive qualities.

The specific benefits provided by uHealth and EI in the care processes include the best quality of care, either by having quick and easy access to specialists or because of the possibility that physicians have more information about the patient. In addition, patients will avoid expenses derived from the “travel cost” and loss of time. They will avoid the inconvenience of traveling, sometimes, long distances to perform additional consultations required to have the opinion of a specialist. The uHealth offers the possibility of collecting, independently of the geographical location, a second opinion for the generation of diagnoses, an improvement of the clinical and therapeutic coordination, and the possibility of support to the doctors who work in isolated areas. The uHealth helps the equity and universality of the health service, improving the continuity of care, allowing the provision of quality health care in the remote areas of the country, and facilitating a shorter length stay in the hospital. The above means a better use of resources and greater speed in incorporating the patient into their usual environment, reducing the need for travel and transportation that should be assumed by the health system (Cabo-Salvador et al., 2018; Cabo-Salvador, 2017).

The use of uHealth allows to achieve an effective interoperability. Thus, each assistance environment (primary care and specialized care) has sufficient information and has the capacity to exchange information in a safe, fast, efficient, and quality way.

As mentioned, we are witnessing a worldwide demographic change. The inhabitants of the most developed countries live longer. Hence, the population is aging at an appreciable rate. Some of the pathologies that are considered chronic nowadays, in addition to others that clinical advances will become chronic, will be a true pandemic worldwide, and the cost of their treatment will be unaffordable, unless the way in which patients interact with the health system is changed. As an example, the new technologies will have a fundamental role in the life of the elderly with cognitive deficiencies or mental disorders. These technologies can also be used to stimulate the intellectual activity of the elderly, with the aim to slow down the cognitive deterioration, as far as possible.

Through ICT, innovative diagnostic and predictive methods are developed around centralized databases with information from multiple patients with clinical, analytical (biochemical and anatomopathological) data, as well as molecular and genetic profiles. Therefore, these data can be integrated with applications that allow presenting, transmitting, and extracting information in the form of individualized and modeled phenotypes with the development of AI algorithms. It allows the design of individualized and optimal treatments according to the type of pathology, which will serve as support tools for the pathology identification, the biological characteristics knowledge, the severity and aggressiveness degrees of the lesion, and the possible resistance to therapies and drugs. As a result, the application of aggressive and expensive non-effective treatments is avoided and it is possible to choose the most appropriate treatment, according to the patient’s personal and clinical profile (personalized medicine). Consequently, they will improve their survival and quality of life, cost-utility result of the procedures or therapies and the QALY ratio [Quality-Adjusted Life Year] in the procedures used.

Certainly, ICTs will lead to savings in the consumption of healthcare resources through the reduction of medical errors, the possibility of avoiding morbidities associated with inappropriate treatments and the best assistance to the patient through evidence-based medicine. ICT will change the doctor-patient relationship with an increase in consultations through the web environment and videoconferences, and through the physical support of robotics using “MD robots”, with remote-controlled mobility and assisted by cameras with audiovisual and reception capabilities, as well as the delivery, the data and images reproduction in real time, and the on-line diagnosis and prescription.

The potential of home-based technologies based on multiple sensors that collect patient data (smart homes) is highlighted. The ICT will play a very important role in the efficiency and control of expenses by avoiding tests duplication, improving the continuity of care, promoting interoperability between the different centers and giving support in home care and chronic management. ICT enhance the development of support systems in decision-making, improve care equity, and rationalize and control pharmaceutical expenditure through electronic prescription. They also facilitate access to diagnostic and therapeutic technologies, guaranteeing their rational use (EBM), and improving assistance, teaching, research, health planning, and public health control through the EMR (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017).

There is a great expectation and a market of more than 10 billion dollars in 2018 and a large field of action for professionals with different possible programming strategies such as the responsive design trend, based on the development of Web pages with HTML5 technology, which is the imagination taken to the implementation. HTML5 is the cornerstone of the W3C’s open web platform, an infrastructure designed to support innovation and maximize the potential that the Web can offer (Cabo-Salvador et al., 2018).

Currently, as mentioned, we are in a paradigm shift in the health model. This model focused on the patient, empowers and encourages self-care and co-responsibility when it comes to managing their chronic situation. For this change of sanitary model, it is necessary: Invest in ICT; educate patients in the management of their disease; promote evidence-based medicine; integrate primary care, specialized care and social services; and change the management model oriented to coordination between the social and health care areas, where telemedicine and telecare can improve the quality of care.

Chronic Patient Management Models

The management (process management) and the integral treatment (socio-health care) of patients with chronic diseases are part of the main current challenges for the health systems of any country. The advance in the management of chronic diseases and in the management of patients with multiple pathologies (patients with two or more chronic pathologies), requires a paradigm shift of our usual concepts of acute patients’ management within healthcare systems and the integral transformation of current conceptual frameworks, where citizens, their environment and their social and health needs are the real center of the health system.

The existing models of patients’ management with chronic diseases that require hybrid processes and care, not only health, but also social (socio-health processes) are few and very young in their approach. All of them are derived from the Chronic Care Management [CCM], developed by Ed Wagner and collaborators in 1992 at the MacColl Institute for Healthcare Innovation in Seattle (WA), to improve the management of chronic diseases within the systems of integrated providers, such as the North American Group Health Cooperative and Lovelace Health System (Wagner, Austin, & Von-Korff, 1996; Wagner, 1998).

This model of care has as its crucial purpose to locate patients, actively and well informed, as a central element of a system that has a dynamic team of professionals with the necessary knowledge and experience (Figure 3). In addition, it recognizes that the Management of chronic diseases is the result of the interactions of three overlapping areas: The community or country as a group, with its health policies, its health model and its multiple public and private resources; the health system, with its funding and provider organizations, and the public and private insurance systems; and the clinical practice with primary and specialized healthcare, identifying those essential interdependent elements that must interact not only effectively and effectively, but also efficiently, in order to achieve optimal care for patients with chronic diseases.

Figure 3.
Chronic Care Model (MacColl Institute for Health Care Innovation, 2013)

This model was the first widely disseminated system. It helped as the basis for all subsequent models, such as the Extended Chronic Care Model [ECCM], used and proposed by the Government of British Columbia (Canada), which emphasizes the importance and relevance of the community context, as well as the importance of prevention and health promotion (Figure 4), and creates the Innovative Care for Chronic Conditions [ICCC]framework of the World Health Organization [WHO].

Figure 4.
Expanded Chronic Care Model (Barr, et al., 2003, p. 77)

Basically, all these models are only variants of Wagner’s original model, which emphasize, on the one hand, the great importance and the urgent need for commitment in the project, not only on the health side, but also on the social part, an integrated form (key to this project). On the other hand, it proclaims the need to promote, at the political and cultural levels, the promotion of health and the prevention of diseases, together with the aim to optimize the use of existing resources, carrying out integral management effectively, effectively and efficiently, through the formulation of integrated socio-sanitary policies (Figure 5).

Figure 5.
Innovative care for chronic conditions framework (WHO, 2002)

This innovative care of the WHO makes several key complementary contributions to the CCM and highlights the need for a unitary and strong health and social policy that can redirect the social health services, and orient them towards the real needs of patients with chronic pathologies, which is a key element of the model with a strong leadership and with collaboration, both interterritorial, as intersectoral. Hence, It provides a real integration of policies, financial sustainability, and trained and qualified human resources.

Patients with multiple chronic diseases (multi-pathological patients), with prolonged needs –not only health, but also social–, with some functional deficit that prevents them from carrying out normal and adequate daily activities –people totally dependent–, are those who consume the greater volume of health resources in a country. For this reason, the creation of new management models valid for their management remains a national challenge. The organization of health care and health care partner, aimed at the management and treatment of these multi-pathological patients is currently improving, but it is necessary to promote and encourage the work of multidisciplinary teams (health professionals and social service professionals acting simultaneously in a synergistic and coordinated way). In this way, comprehensive and equitable health care can be guaranteed, offering: The continuity of long-term care together with an improvement in the quality of care; a more rational use of resources, both human, structural and financial employees (efficiency); and the improvement of the patients’ life quality and their family environment.

In order to achieve this purpose, a classification is initially required to carry out the first step: Definition of the people identification criteria who are susceptible to inclusion in the need for integrated health care.

A stratification based on the description of the Kaiser Permanente Pyramid (Figure 6) could facilitate the classification of these patients in three levels of intervention, according to their level of complexity. The group of patients that is located in the upper part of the pyramid, although they represent only between 3% and 5% of the cases, are the most complex and those that consume the highest portion of the health and social resources. Therefore, it is necessary to assign comprehensive care plans designed ad hoc to reduce the unnecessary use of specialized resources and, mainly, to avoid hospital admissions (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017).

Figure 6.
Kaiser Permanente pyramid of risk stratification (Goodwin & Curry, 2008)

This risk stratification was developed in the United States of America to classify patients depending on their level of complexity and the probability that their health deteriorates. It locates at a zero level the healthy members of the population for whom the priorities are prevention and early diagnosis of the disease. In the first level is located people who have some kind of chronic disease and who do not have dependence degrees. They represent between 70-80% of chronic patients. Their interest is practically oriented to self-care, appropriate administration of medications and education in health aspects. Their social and health support needs are low. In the second level, high-risk chronic patients are located, which represent 15% of chronic patients and require a more direct management of the disease and greater socio-sanitary support. At the third level are located patients identified as complex, to whom guided care plans are assigned, called “case management projects”, designed to reduce the inappropriate use of specialist services and avoid hospital admissions (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017).

This Kaiser Permanente model has inspired additional approaches, such as the Guided Care Model, where primary care nursing staff, previously trained and qualified and in coordination with a medical team, deals with assessment, evaluation, planning, care, follow-up and supervision of complex chronic patients identified through prediction models previously performed.

Regardless of which model is chosen, it is required models specifically designed to improve the management of chronic diseases and patients with multiple pathologies, since there are no practical clinical guidelines that address multiple conditions. Additionally, it is required new models designed to allow care professionals -primary and specialized- to consider the individual circumstances and preferences of patients with multiple chronic diseases with the purpose to carry out a multidisciplinary integration with professionals of the healthcare environment and the social care environment.

In addition to the management model, it is necessary to create quality standards for social health services for these patients with multiple chronic pathologies, particularly in relation to the care coordination, the education of patients and caregivers, and training in support for self-care, considering individual preferences and circumstances, and incorporating tools to improve social healthcare processes with the help of new technological tools, such as mHealth and uHealth, nanotechnology and EI, as well as the development of services beyond the limits of the current health system. Thus, there are required information systems that provide data, both from the patient and from the health aspects, that can be obtained directly from the exploitation of the Minimum Basic Data Set [MBDS], as well as additional information on social and socioeconomic aspects, which makes decision-making easier for managers (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017).

New Integral Model of Socio-Health Resources Management

Our new model consists, first of all, of a social and health information system [Sistema de Información Socio Sanitario, SHIS] that will allow: The assessment of the inclusion criteria to the different offers of the social health services portfolio, and share a social and health integrated record [Historia Socio Sanitaria Integrada, HSSI], the obtaining of a MBDS specific for health and social issues [MBDS-HS] and the obtaining of risk adjustment systems that allow us to know the cost of socio-health processes. Hence, it will be possible to make an efficiency and quality benchmarking, as well as assign resources based on the costs obtained in the different processes of the health and social services portfolio, something impossible with current information systems.

An HSSI will allow the managers to:

• Register patients and assign them an identification code;

• facilitate the follow-up of the social health process with an ABQ [Activity Based Quality] methodology focused on the quality of care, knowing how the healthcare-based healthcare processes are carried out [Activity Based Management, ABM] and what is the cost of each process [Activity Based Costing, ABC], all of the above as the axis of the patient process with social and health needs that has been defined as a person susceptible to inclusion;

• be able to track through a scorecard of the entire process; and

• carry out an evaluation and benchmarking with the health and social information that is available in an HSSI, interoperable and accessible, both from the social area and from the health area.

In addition to the SISS, the HSSI and the MBDS-HS, a system of risk adjustment will be required through an Aggregate Set of Social Attention [Conjunto Agregado de Atención Social, CAAS] that allows to know the cost of social processes, in order to make benchmarking of efficiency and quality and consequently allocate resources according to the costs obtained in the different processes of the social services catalog.

For that, it is necessary to carry out some Integrated Social Care Guidelines [Guías Integradas de Atención Social, GIAS] in order to standardize the processes, and a new Model of Cost Assignment to the Social Care Processes [Modelo de Asignación de Costes a los Procesos de Atención Social, MacPAC], in order to define a Tool for the Evaluation of Results in Social Care [Herramienta para la Evaluación de Resultados en Atención Social, HERAS].

A diagnosis of the social needs, the objectives of coverage, the strategic lines and the suitable actions for its achievement, and a forecast of its evolution are the basis of the planning. The mechanisms of systematic and continuous evaluation are the guarantee of execution with quality. These tools provide transparency in the service agreements between the companies, the suppliers, and the financial administration.

All this frame of models reference, tools and methodologies constitutes the Management of Assistance Resources in Social Care Integral Model (Health Partner) [Modelo Integral de Gestión de Recursos Asistenciales en Atención Social (Socio sanitarios), MIGRASS] (see Figure 7 and Figure 8), which follows the pattern initiated in health, which has originated products such as the Diagnosis-Related Groups [DRG], the Adjusted Clinical Groups [ACG] and similar ones. It also looks for common aspects in the social services users that allow the establishment of classifications and the attention processes arrangement, providing them with indicators and being able to compare their performance and their results effectiveness.

Figure 7.
MIGRASS Model

Figure 8.
MIGRASS Model

This new integrated management model will allow to:

• Register users of social services univocally and get a comprehensive view of the services they use and their family environment or coexistence;

• facilitate the monitoring of the social process with an ABQ methodology focused on the quality of care, knowing how the ABMs are performed and what is the ABC of each process;

• be able to follow up through a scorecard of the whole process; and

• evaluate the effectiveness of social actions by an integrated social information.

So, taking advantage of the social integration momentum, it is suggested to complement with the development of tools that effectively allow planning, designing, measuring, comparing, and provisioning the set of our processes allowing to:

• Identify and classify users;

• order and group the processes of our social services catalog in aggregate sets of social care;

• evaluate these processes and establish reference indicators;

• measure the execution of the processes through a tool that allows the actors to evaluate the performance of the institutions under their responsibility;

• analyze the results and predict the demand and resources consumption; and

• be able to make adjustments and planning.

One of the fundamental elements of MIGRASS is the tool for the costs allocation to social assistance processes, which is very useful for assessing the cost of each CAAS and for establishing and making comparisons. It is the module of costs allocation derived from the GRASS and CAAS by citizen, for the different cost centers. It implements an accounting method that allocates the costs with a tree-like detail according to the total expenditure in a certain period of time.

MacPAS is the tool that allows modeling and defining a costs system associated with social care processes. Similar to other areas, the need for a cost model is evident in health. For that reason, a cost-setting system based on the ABC methodology is introduced as support for the social assistance processes. Its philosophy is based on the principle that activities are really the causes that determine the resources consumption and the subsequent costs. In the social field, this system identifies the activities carried out in the process and employs cost drivers that allow the costs of these activities to be transferred to the different products or services, depending on the social processes carried out. In that way, the centers or departments incur costs as long as they carry out activities, and the cost of the products results from the consumption of the activities necessary to obtain them.

A significant aspect of cost systems based on activities is their orientation towards activities. In this case, if reliable and correct information is generated, relative to those activities that are not important in social care, a significant reduction in the tasks or associated work could be achieved, which, in any case, would induce a costs reduction and a quality improvement.

Considering the ABC system, it should be noted that the cost measurement structure is conceived on each of the intervening cost centers, and therefore includes, within these considerations, all the costs associated with the social care of the citizen, in all possible areas (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017).

Health System Sustainability (efficiency) and Quality of Care Improvement

During the last decade of the last century we have witnessed a remarkable growth of the residential and non-residential gerontological care sector (day centers, tele-alarm, home help services, etc.). The public sector has promoted the creation of places for dependent elderly people care with different models or management systems. Public management centers have scarcely been created. On the contrary, the private management of public places (private integral management of public centers, private management of agreed places, direct financing to the user as a check-bonus, etc.) is the modality that the public sector considers more efficient. However, according to this type of management, it is essential to know the production and quality of the services provided for public administration.

This objective is difficult to carry out due to several causes, among them:

• The concept of evaluation of services immaturity;

• the insufficient definition of the services catalog in the sector, which creates enormous confusion when comparing structures of centers, services portfolios and programs, users’ types and results; and

• the lack of a reference management model that causes a different management model in each center, and that professionals or services from a similar activity perform under non-comparable production parameters.

In this way, the universality and importance of dependence situations has led to multiple disciplines and professionals who are responsible for their analysis, providing multiple data, which comes counterproductive, due to the diversity of activity scales and classification of users of social assistance methods (see Figure 9).

Figure 9.
Products and services homogenization schematic model

The main objective of the social health management integrated model as a whole is the analysis of the GRASS in the social assistance system, for use as a financing or budgetary tool in the Public System of Social Services. The above, through the proposal of a first inventory for related groups, designing as base the Social Space Minimum Basic Data Set [SSMBDS]. For each of the GRASS, it is necessary to develop the information related to the activities, consolidating a first approximation to the process standard or to its GIAS, which must include: A global process diagram, in which the different functional services are perfectly identified, carrying out activities throughout it; the interrelationships between them; and the resources used (time and materials).

Once the resources are known, the costs are imputed, in order to obtain the cost per process. The direct costs (personnel, materials and assistance) would be derived from the description made in the GIAS. To calculate the indirect costs, it is necessary to allocate them based on some distribution criteria determined in a consensual manner with the competent authorities in the management of social services. The latest phase requires information from historical databases and participatory decision-making with those directly responsible for social services and processes (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017).

Efficient and Quality Social-Healthcare

Nowadays, there is a generalized awareness of the important contribution that new ICTs have in our society, mainly in aspects related to the health and well-being of people since we tend towards an aging population, in which people become chronic patients with multiple pathologies that need continuous care over time. The traditional acute patient profile is changing, he needs, not only timely access to health resources at acute illness times but coordinated attention and care through different types of socio-health specialists, with the purpose to receive appropriate treatment with your needs. The current acute management model is not useful. So, it is necessary to have a health model based on timely attention to critical health situations and specialized care in health centers or hospitals. In the change of health model it is required to include new actors and services in the value chain, and make a radical change in the conception of the health system, considering a patient-centered matrix health system, with doctors, nurses and other socio-health professionals who interact in a comprehensive manner in the case (Barr, et al. 2003; Beaglehole et al., 2008; Bodenheimer & Berry-Millett, 2009; Boult et al., 1999; Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017; Gravelle et al., 2007; Hébert et al., 2009; Kane et al., 2002; MacAdam, 2008; Oeseburg et al., 2009; Ouwens et al., 2005; Pearson et al., 2005; Rosen & Ham, 2008; Singh, 2005; Sylvia et al., 2008; Vickers et al., 2006; Weiss, 2007; Wolff et al., 2009; Zwar et al., 2006).

At this point, ICT can be a key tool in this process of change. Thanks to the use of telemedicine and telecare solutions it is possible to provide elderly people with social-health services in their own home, and with affordable costs, which cannot be addressed in any other way. It is possible to have collaborative work tools, based on their integration with interoperable HCE systems, which allow socio-health professionals to access all the patient’s multi-pathological information, and coordinating all the actors in the healthcare value chain that meets the needs of the chronic patient. On the other hand, social networks will provide tools for the elderly self-care and self-management, allowing them to address common problems such as loneliness, depression, and lack of mobility, which degenerate into physical and psychological problems that deteriorate the state of health of the person.

In addition, this model offers closer and specialized care for patients with one or more chronic health problems. They are some of the main beneficiaries of this type of care, much more continuous and individualized, which gives greater security to people, their families and caregivers at all times.

The increase of years in the life expectancy, the increase of people with multiple pathologies, the changes of roles in the care of Spanish families and the application to the ICT sanitary field, assist health managers to reorient their organizations and change their strategies, establishing tactical alternatives to face these new challenges. In addition, it is important to consider that the cost of patients with more than one chronic disease multiplies exponentially with respect to those who are only carriers of a disease (Cabo-Salvador et al., 2017; Cabo-Salvador et al., 2018; Cabo-Salvador, 2017).

Conclusions

It is necessary to reorganize and manage efficiently the social and healthcare models, considering primary care as a predominant role, with greater care integration between primary care and hospital care, improving interoperability and continuity of care between them.

New integrated management models by processes are needed through an evidence-based medicine, using consensus clinical guidelines and case management where the family members or socio-healthcare providers play an important role in the process of chronic patient care.

It is necessary to manage diseases, with an increase, both in preventive medicine and in proactive medicine, focused on the patient, and through an adequate socio-sanitary attention to their needs in their closest environment (Home Care), in order to avoid patient displacements, unnecessary hospital admissions, and an indiscriminate use of emergency services.

All the above have an impact on a better quality of care and on the reduction of structural and functional costs, as a result of the decrease of the number of emergencies, hospital consultations, and hospital admissions; as well as the decrease of the diagnostic tests duplicity; and interactions and drug iatrogenies. It will result in a decrease of health expenses, system inefficiencies, and existing bottlenecks.

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Author notes