Juan Carles Contel, Department of Health, Chronic Care Program, Catalonia
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This document discusses the journey of the Catalan healthcare system from a chronic care program to a model of integrated health and social care. It outlines the chronicity prevention and care program that aims to provide integrated care through strategies like identifying complex chronic patients, developing integrated clinical care pathways, and promoting self-care and collaborative care models. It also provides data on the Catalan population's demographics, healthcare facilities, and efforts to stratify patients based on their health risks to better provide proactive and targeted care.
Juan Carles Contel, Department of Health, Chronic Care Program, Catalonia
- 1. The journey from a Chronic Care Program towards a model of Integrate health and social care
- 2. Session structure • A new Health Plan and the introduction of a new STORY • Chronicity Prevention and Care Program: the “journey” toward Integrated Care • Towards a new evaluation framework: The first results • A new journey toward a new Integrated health and social care model • Promoting self-care of the patient and citizen: Catalonian Expert Patient Program. Towards new Virtual care model
- 3. Catalan Healthcare System: some basic features • Area: 32,106 km2 • Population: 7,611,711 inhabitants. 17% over 65 y. (expected 32% in 2050) • 1780 € expenditure per capita and 1150 € public expenditure per capita in 2012 • Life expectancy: 82.27 years • Gross Mortality rate (2010):8/1,000 inh. • Infant mortality (2010): 2.6 /1,000 live births • 369 Primary Health Centres (PHC) ranging from 20-45,000 inh) • 69 “acute hospitals” (no far from 50 Km. from every home) • 96 health-social centres (residential homes: long-stay, convalescence, pal.liative care) • 41 Mental Health Centres
- 4. Catalan Healthcare System U S E R SERVEI CATALÀ DE LA SALUT 100% SUPLEMENTARY PRIVATE INSURERS 20% INSTITUT CATALÀ DE LA SALUT 20% PRIVATE CENTERS 10% P S NCONTRACTED PROVIDERS 70% Insurance Services
- 5. Source: Catalan Health Plan 2011-2015. The Catalan Health Plan 2011-2015 Health Programs: Better health and quality of life for everyone Transformation of the care models: better quality, accessibility and safety in health procedures Modernisation of the organisational models: a more solid and sustainable health system I II III For each line of action, a series of strategic projects will be developed, which make up the 31 strategic projects of the Health Plan. 9. Improvements to information, transparency and evaluation 1. Objectives and health programs 7. Incorporation of professional and clinical knowledge 6. New model for contracting health care 5. Greater focus on the patients and families 8. Improvement of the government and participation in the system 2. System more oriented towards chronic patients 3. A more responsive system from the first levels 4. System with better quality in high-level specialties
- 6. 2.1 Integrated clinical processes 2.2 Protection, promotion and prevention 2.3 Co-responsibility and self-care 2.4 Alternatives in an integrated system 2.5 Complex chronic patients 2.6 Rational prescription and use of drugs Strategic lines of the program
- 7. 7 An increasing number of elderly 5,2% 5,5% 5,7% 6,1% 6,5% 7,2% 8,2% 9,7% 11,2% 13,8% 17,0%17,2% 19,6% 24,1% 29,2% 31,9% 0,6% 0,7% 0,7% 0,7% 0,9% 1,0% 1,2% 1,5% 1,9% 3,0% 3,9% 5,1% 5,9% 7,2% 9,4% 11,8% 0,0% 5,0% 10,0% 15,0% 20,0% 25,0% 30,0% 35,0% 1900 1910 1920 1930 1940 1950 1960 1970 1981 1991 2001 2011 2021 2031 2041 2049 > 65a > 80a Source: INE, projections 2011 1/3 of population will be over 65 and 12% will be over 80
- 8. Chronic Care Program essential conceptual aspects • Oriented to people and their needs • “Population” approach: designed and made for all • Promotes healthy lifestyles • People participate from joint responsibility and self-care • Caregiver and family as main agents in the process of caring • Social and health approach with a vision of integrated care • Promotes sustainability and equity of the health system • “Territorial “ (population based) vision with required Integrated Care
- 9. Healthy 33% Chronic non complex 62% Complex 3,5% Advanced 1,5% End of life Bereavement PREVENTIVE APPROACH CURATIVE APPROACH PALLIATIVE APPROACH SELFCARE COLLABORATIVE CARE The continuum of chronicity
- 10. Healthy 33% Chronic non complex 62% Complex 3,5% Advanced 1,5% Terminal Bereavement PREVENTIVE APPROACH CURATIVE APPROACH PALLIATIVE APPROACH SELFCARE COLLABORATIVE CARE Integrated Clinical and Care Pathways
- 11. • Integrated Care Pathways as a formal agreement among professional clinical leaders at local level • Based on reference clinical guidelines • How to implement best evidence practice • Critical key points identification • Critical variables uploaded at Shared Clinical record • 80% of territories implemented 3 of 4 chronic conditions: COPD, depression, heart failure and DM2. Now Complex Cronic Care Pathways work • Other 6 conditions to be included in the future 11 Integrated Care Pathways
- 12. Healthy 33% Chronic non complex 62% Complex 3,5% Advanced 1,5% End of life Bereavement PREVENTIVE APPROACH CURATIVE APPROACH PALLIATIVE APPROACH SELFCARE COLLABORATIVE CARE Taking care of complex patients
- 13. Taking care of complex patients ▪ Stratification model /predictive model ▪ Model of care for patients with complexity ▪ Palliative care-oriented model in persons with advanced chronic disease ▪ Collaborative model between health services and social services: integrated health and social care
- 14. 14 Multimorbidity unified data base Insured data source NIA, demographic data Diagnosis data base NIA, tipus_codi, codi, data dx ,UP, tipus_UP “Contact” data base NIA, dates contacte ,UP, tipus_UP, urgent, CatSalut, T_act. MDS-Hospital MDS-PHC MDS-MH MDS-NH MDS-A&E Central Registered Insured Health Problems Pharmacy (PHC and hospital provided) Pharmacy data base NIA, ATC, data dispensació, unitats, Import Mortalitat (INE) Data sources Divisió d’Anàlisi de la Demanda i de l’Activitat
- 17. 17 PCC Multimorbidity Severe unique disease Advanced frailty MACA Limited live prognosis Palliative approach, Advance care planning Two profiles of complexity
- 18. -Care centres that have patients classified and marked in these two types, can publish this label/mark in HC3 - The classification / label must be visible on all the screens , given the importance of the condition - It has been incorporated in July 2013 version to HC3 stratification with Clinical Risk Groups (CRGs) PCC: Complex Chronic Patient MACA: Advanced chronic disease
- 19. NUCLEAR CARE MODEL IMPLEMENTATION SUPPORTING GUIDE Source: PPAC 2013. Departament de Salut NEW INDIVIDUAL ACTIONS TEAM REDESIGN TERRITORY COMPLEXITY CARE PATHWAY Basic requirements Optimal provision Excellence
- 20. 9980 1765 11745 18632 3613 22245 32100 5400 37500 64117 12300 76440 0 10000 20000 30000 40000 50000 60000 70000 80000 90000 PCC MACA TOTAL 15 April 31 May 31 July 31-des Initial Health Plan target(!): 25.000 complex chronic patients should be identified by 2015 At March 2014 over 80.000 patients included Evolution of PCC / MACA with a collaborative intervention plan in shared IT “Labeling” available since January 2013 !
- 21. “Shared Individual Intervention Plan” (PIIC) Health problems/Diagnosis Active Medication Allergies Reccommendations for “in cases of crisis” or exacerbation Advanced Care Planning Resources and services used Multidimensional assessment Carer whom are delegated decisions Additional information of interest
- 22. Check list for support of deployment complexity care model Basic and Priority: “PCC” and “MACA” identification and labelling + Integrated Care Pathway + 24 / 7 model + Carer identification and support
- 23. Level 2 Chronic patients at risk Case Management Disease Management Self-care suport Level 1 People with stable chronic diseases at early stage Level 3 Complex chronic patients Comorbidity, emergency hospitalizations, A&E visits, moderate and severe dependency, polypharmacy HEALTH PROMOTION Healthy people WHO do we like to identify people at risk?
- 24. 24 Multimorbidity unified data base Insured data source NIA, demographic data Diagnosis data base NIA, tipus_codi, codi, data dx ,UP, tipus_UP “Contact” data base NIA, dates contacte ,UP, tipus_UP, urgent, CatSalut, T_act. MDS-Hospital MDS-PHC MDS-MH MDS-NH MDS-A&E Central Registered Insured Health Problems Pharmacy (PHC and hospital provided) Pharmacy data base NIA, ATC, data dispensació, unitats, Import Mortalitat (INE) Data sources Divisió d’Anàlisi de la Demanda i de l’Activitat
- 25. Clinical Risk Groups and levels of aggregation Standard aggregation 1.000 groups (CRG) Aggregation in groups St. 9: High need condition St. 8: Severe neopl St. 7: Chronic cond. 3 or more organs St.. 6: Chronic cond. 2 organs St. 5: Chronic condit. St 4: Minor chronic cond. diff. organs St. 3: Minor chronic cond. St. 2: Acute condition St. 1: Healthy History of Heart Transplant Metastatic Colon Malignancy Heart Failure + Diabetes + COPD HF + Diabetes Diabetes Migraine+ Hiperlipidemia Migraine Pneumonia Healthy 1 4 1 4 1 6 1 6 1 4 1 4 1 2 Health Status CRG Basic Severity In the standard aggregation (health status, basic CRG and level of severity) we obtain a basic information about health status and level of severity in less than 40 groups HealthStatus Severity Level Status 9 Status 8 Status 7 Status 6 Status 5 Status 4 Status 3 Status 2 Status 1 1 2 3 4 5 6 More than 1,000 groups. Too much !!!
- 26. Stratification and Emergency admission risk CRG RSC Identification people at risc Proactive measures Classification people at risk Segmentation for the proactive management of people at risk Identification and recording at Clinical Record
- 27. How does it work the morbidity “grouper” Population Grouper Classification (Stratification) Intervention Follow-up CRG: Clinical Risk Group Risk Adjustment per morbidity IdentificationKey concepts
- 28. Returning population stratified data base Chronic disease selection Hospitalization s Risk ID DM HF COPD Asthma Other: Nº emerg admis ssion Hospital Cumulat ive days CRG (status and severity) Hospitaliz ation Tax Mortality Tax ZAGO234… 1 1 0 0 1 3 18 7.4 80% 40% ROGU675.. 1 0 1 0 1 1 8 7.3 65% 28% Selection of patients by different criteria Different pyramids related to different Risk approach: Future hospitalization / Death / Future cost
- 29. 1% 18% 133% 10.992€ 13% 13% 2% 7% 57% 5.872€ 13% 26% 8% 3% 28% 3.162€ 28% 54% 17% 1% 14% 1.411€ 25% 79% 72% 0% 2% 282€ 21% 100% POPULATION MORTALITY TAX HOSPITALI- ZATION TAX ESTIMATED EXPENSE % ACCUMU- LATED Impact distribution of different segments
- 30. Different utilization of Stratification • To adjust models of “per capita” financing, assigning different budget related to morbidity burden in each PHC • To identify populations and population segments with higher multimorbidity burden and more RISK of.........................: Emergency hospital admission High Cost High pharmacy consumption High mortality Higher Social Services Utilization • To assign “individual” RISK: not yet well calculated, we need more variables to be included and should accept limitation of these tools • How to incorporate Stratification scores into Information Systems: Visualization and access to Shared Clinical Record and local clinical record Return of data base to local providers • Validated model in American population or an own national/regional model ?
- 31. Visualization in Shared Clinical Record and different RISK scores Morbidity group and RISK calculated and published twice a year Description of different RISK segments
- 32. CRG information (morbidity group), severity and Hospitalization Risk • CRG 7/5 • 3 emergency admissions • Hospitalization Risk of 35% PCC/MACA Included in “CASE MANAGEMENT” Program CRG and Risk score visualization
- 33. PATIENT SELECTION by CRG + Nº emergency admissions last 12 months + Hospitalization RISK next 12 months
- 34. Current situation chronic patient avaluation Indicators Primary Care Hospital Care Avoidable Hospital Admissions + - Home Care program Coverage + - Health outcomes: good control, process and treatment ++ - Readmission rate in chronic processes: Chronic Obstructive Pulmonary Disease (COPD) and Heart Failure (HF) - ++ COPD/HF Avoidable Hospital Admission - - Discharge planning in “PRE-Discharge” program - + To ensure continuity care in “POST- Discharge” program + - “Quality of life” (HRQoL) assessment - - Fragmented care and fragmented evaluation framework
- 35. New evaluation vision: “Triple Aim” Population Health Experience of Care Per Capita Cost • Health Outcomes Indicators incorporates in evaluation Primary Health Care (PHC) (good control chronic diseases, vaccination..) • Quality of life • Satisfaction • PROM • Costs • Service utilization: Avoidable Hospitalizations , Readmissions,… Evaluation and commissioning of ”Integrated Care”
- 36. Proposed future chronic patient indicators Indicators Primary Care Hospital Care Avoidable Hospital Admissions ++ ++ Home Care program Coverage ++ - Health outcomes: good control, process and treatment ++ ++ Readmission rate in chronic processes: Chronic Obstructive Pulmonary Disease (COPD) and Heart Failure (HF) ++ +++ COPD/HF Avoidable Hospital Admission ++ ++ Discharge planning in “PRE-Discharge” program ++ - To ensure continuity care in “POST- Discharge” program - ++ “Quality of life” assessment ++ ++
- 37. New contract 2013: Common PHC-Hospital Targets 37 COMMON TRANSVERSAL OBJECTIVES(20%) Reduction Avoidable Hospital Admissions Rate (composite, HF and COPD) Reduction 30-day Readmission Rate for HF and COPD (also composite) Get minimum value prescription pharmaceutical index % minimum discharges with contact before 48 hours after discharge % minimum register screening risk factors Metabolic syndrome TMS ESPECIFIC TRANSVERSE OBJECTIVES (“TERRITORY”) (20%) % minimum PCC/MACA with Intervention Plan (“PIIC”) % minimum PCC/MACA with medication review % minimum PCC/MACA with post-discharge medication conciliation Reduction emergency admissions in PCC/MACA Minimum number participants Expert Patient Program % minimum COPD patients with spirometry % minimum PHC with Mental Health integration Prevalence minimum depresion with “severity” criteria % minimum patients with depresion with “suicide risk” assessment Development at local level a consultant virtual office “Amputation rate” reduction in DM “Ophthalmology/locomotor “ referral first visits under expected tax
- 38. HTA: TA good control +1,6% last year variation 55,67 59,34 62,14 63,89 65,60 68,60 69,70 50 55 60 65 70 75 Jan 2007 Dec 2008 Dec 2009 Dec 2010 Dec 2011 Dec 2012 Dec 2013
- 39. Multidimensional assessment in Home Care +4,4% last year variation 29,05 65,11 68,63 78,43 81,53 88,50 92,40 0 10 20 30 40 50 60 70 80 90 100 Gen 2007 Des 2008 Des 2009 Des 2010 Des 2011 Dec 2012 Dec 2013
- 40. Heart Failure: patients treated with ACE +0,8% last year variation 67,64 71,12 72,93 75,09 75,48 77,00 77,60 62 64 66 68 70 72 74 76 78 80 Jan 2007 Dec 2008 Dec 2009 Dec 2010 Dec 2011 Dec 2012 Dec 2013
- 41. • Indicators of admissions for every Sector and Primary Health Team • 14 chronic diseases • Benchmarking with different standards among PHT and Hospitals Servei Català Salut. División de Registros MSIQ. Quality measures MSIQ: http://146.219.25.61/msiq/index.html
- 42. Hospital admissions for ACSC ‘Composite’ avoidable hospital admissions at December 2013 Monthly udpated information! Includes: COPD, HF, pneumonia, DM complications, asthma, urinary infections, dehidratation, HTA Availability of evolution of avoidable emergency admissions for ACSC per region / sector / PHC team Source: MSIQ, Catsalut −6 % last 24 months
- 43. Potentially avoidable hospital admissions for COPD Decrease by 14,8 % from Dec 2011 to Dec 2013 (24 months) Availability of evolution of avoidable emergency admissions per region / sector / PHC team Source: MSIQ, Catsalut
- 44. Potentially avoidable hospital admissions for heart failure Source: MSIQ, CatSalut Decrease by 2% from Dec 2011 to Dec 2013 (24 months) Availability of evolution of Avoidable Emergency admissions per Region / Sector / PHC Team New trend! Increase by 25% from 2006 till 2011
- 45. Heart Failure COPD Avoidable Emergency Admissions in ACSC Available information at Primary Health Care Centre level Diabetes complications Asthma
- 46. 30-day readmissions 90-day readmissions 30-day Readmissions per Heart Failure per Hospital area
- 47. Expected per capita expenditure The 1% of top consumers spend 1.701,5M €, the 23% of total cost with an average of 21.540€ per cápita costThe 5% of top consumers, spend 3.783,6M €, 51% of total cost with an average of 9.580€ per cápita cost Average expenditure (€) Percentiles related to expenditure
- 48. Expected per capita expenditure Average expenditure (€) Primary Care Pharmacy Emerg.adm. A&E Outpatient Clinics AGE Primary Care Pharmacy Emergency admissions Outpatients clinics
- 49. Expected per capita expenditure Average expenditure (€) Primary Care Pharm. Emerg.adm. A&E Outpatient Clinics COPDDiabet. Dement Card. CVAMent. Cirros. Kidney H. Fail. Neopl.VIH Primary Care Pharmacy Emergency admissions Outpatients clinics
- 50. Hospital admission by diagnostic groups > 70 y. 0 4000 8000 12000 16000 Hipertensió essencial Deliri, demència i altres trastorns cognitius i amnèsics Trastorns del metabolisme hidroelectrolític Asma Infeccions i ulcera crònica pell Diabetis mellitus amb complicacions Hipertensió amb complicacions i hipertensió secundària Pneumònia per aspiració d'aliments o vòmits Infeccions de vies urinàries Pneumònia (excloent-ne per tuberculosi i MTS) Malaltia pulmonar obstructiva crònica i bronquièctasi Insuficiència cardíaca congestiva 70 and more Pneumonia Source: DGPRS. Dep Salut, 2013 COPD HF Urinary Infection Asthma Diabetes with complications
- 51. Large differences in Hospital admission rates by sector (x 1.000 hab) for people over 70 y. 0 20 40 60 80 100 120 Taxa crua Taxa estandarditzada
- 52. 2.5. Complex Chronic Patients deployment ▪ To define a stratification model that allows segmentation of the population with chronic diseases with different risk levels. Creating a predictive model that incorporates risk situation at Shared Clinical record. ▪ To design Complex Chronic Patient Care Model (PCC). ▪ To design care model for people with advanced chronic disease. ▪ To define collaborative model between health services and social services: design care a collaborative model, access to “Shared her” by social services and incorporation to it information of common interest, identifying common targets in contracts Department of Health and Department of Social Welfare. PROGRAMA PREVENCIÓ I ATENCIÓ A LA CRONICITAT
- 53. Integrated Health and Social Care is high priority and policy in England https://www.gov.uk/government/ policies/making-sure-health-and- social-care-services-work- together
- 54. Direcció d’Atenció Primària Costa de Ponent
- 55. Integrated Care in Torbay PROGRAMA PREVENCIÓ I ATENCIÓ A LA CRONICITAT
- 56. Integrated Care Model and Social Services Mrs Smith in Torbay
- 57. Basis for a Social and Health Integrated Care Plan for Catalonia: PAISS
- 58. 25th February 2014: New Government Agreement where is launched a new Integrated Health and Social Care Plan in Catalonia Accountable and reporting to Department of Presidency
- 59. Catalonian Integrated Care model: Set of elements support Integrated Care Multi-lever approach: ALL things at the same time Integrated Care pathway: •Multiprofessional work around Primary Care •Care Transitions •Residential Care •24/7 model Joint Assessment + Joint Intervention Plan Stratification: assessing population needs Clinical and professional leadership Governance: Health and Social care Boards Shared Outcome Framework and joint accountability Aligned Incentives and Integrated Commissioning Shared clinical and social care record Culture and change management Self-care ENABLERS
- 60. PIAISS Integrated Care project: operational approach 1. Integrated health and social care approach for people with health and social needs, including mental health. 24 / 7 2. Joint caseload, joint assessment and joint intervention plan for risk and vulnerable people with health and social needs 3. Converting high intensive institutional long-term care into home and community care with comprehensive services 4. Primary Health teams as main providers of residential care 5. Population Stratification including social data 6. Integrated/shared ICT: Shared health and social care record 7. Shared Integrated Care Outcome Framework. Triple Aim orientation. Single Commissioning Agency in the future 8. Promotion of bottom up experiences based in PIAISS values and principles 9. Self-management approach. 10.Strong involvement of clinical and professional leadership 60
- 61. How to conduct a collaborative model? Local Operational Plan Situation analysis (through SWOT analysis or any other methodology for analysing): starting point, barriers, facilitators, opportunities and threats. External and internal analysis. Planning: defining an action plan, operational objectives, action lines and operationalized and calendarized actions. Communication and implementation: risk analysis tools as well as control and monitoring tools will be used, transversal implementation considerations such as quality, communication, training will be taken into account. Assessment: the project’s assessment and monitoring model, as well as participating agents’ responsibilities, assessment commissions and reports to be created should be defined. 61
- 62. How to conduct a collaborative model? 1. Environmental and internal analysis at local level Minimum internal and external situation analysis / Identify critical elements enabling the building of proposals to be collected in ‘Local Operational and Functional Plan’ (LFP) / Highly operational guidance and implementability with short terms results. 2. Integrated operational care model Operational approach promoting common space and time. 3. Define and use a “territorial governance board” Strategic governing body / steering group / implementing group 4. Define a common porfolio for people/users Complex Chronic care and dependence / Home nursing and home help service (SAD) / Hospital discharge planning / Institutionalized people / Mental health / Childhood at-risk / Abuse / Active aging, health promotion and disease prevention / Other 62
- 63. How to conduct a collaborative model? 5. Shared information systems: constructing a new eClinical and Social care record • Identify the person with the CIP (Identification Number) as a common identifier. • Prior agreement on the coding and register of social problems. • Prepare the local social services information system for it to be ‘interoperable’ in a short-medium term and provide a minimum set of information and variables for a Shared Social and Clinical Record model. • Access to a minimum set of information and variables of common interest on social field for the Shared Clinical Record of Catalonia (HCCC). Later stage: HCSC fed with input from both health and social parties. 1st stage: generation of a Social Intervention Plan incorporated to HCSC. 2nd stage: Shared Individual Intervention Plan. • Communication systems to improve accessibility, messaging and virtual work between social and health areas. • Introduce social variables gradually to available health stratification. 63
- 64. How to conduct a collaborative model? 6. Selection of people based on cross-database and lists of people from social and health areas and stratification (!!!) 7. Definition of guaranteed protected pathways in transitions (discharge planning + post discharge support) among services and in crisis situation and proactive planning. 8. Dependence assessment and recognition procedure optimized with a guaranteed maximum response time. 9. Incorporation and definition of roles and responsibilities of different professional profiles (esp. Social workers working in PHC 10. Accountable professional reference for complex cases. 64
- 65. How to conduct a collaborative model? 11. Common and transverse Shared/Single Outcome Framework with incentive alignment. Progressive process. Triple aim vision: health results and good care, service utilization and good perception of care. 12. Definition and implementation of an integrated home care model. 13. Joint action plan for promoting autonomy, active aging, health and well being and disease prevention incorporating the role and collaboration of telecare services. 13. Accessibility solutions and joint technical assistance from a territorial perspective. 14. Incorporation of the third sector. 65
- 66. North Ireland is developing and Integrated health and social care record !!!
- 67. “PCC / MACA” condition Shared Individual Intervention Plan (“PIIC”) Diagnostics/ Health problems “Dependency degree” formal assessment “Home Help” services label “Telecare” services label Social Care Intervention Plan Pharmacy prescription Health Care Social Care + Social “Health and Social” Integrated eCare Pilot project in pioneer territories
- 68. 1. Structure: existence Local Functional Plan (LFP) containing a minimum analysis of situation, action and evaluation proposals 2. Accessibility: time access to Social Services and Primary Health Care 3. Activity: Minimum number or coverage of users or people attended jointly by evaluation year Minimum number of coordination meetings structured and planned annually 4. Satisfaction of users when covered by program together. Quality of Life assessment 5. Professional Satisfaction 6. Service Utilization: Avoidable potentially hospitalizations in chronic diseases, 30-day readmissions,… Looking for a Shared Outcome Framework to promote Integrated Care with Social Services
- 69. ® 212 PHT 2 HOSPITAL 316 GROUPS 3191 PARTICIPANTS 233 EXPERT PATIENTS 649 PROFESSIONAL OBSERVERS ACTIONS 2006-2013 Source: Programa Paciente Experto Catalunya® 2013