Modeling approach to managing the deployment of integrated organizational models for multi-morbid patients in the CareWell study. The Basque Country case

Abstract

Introduction: An integrated care approach supported by information and communication technologies (ICT) is being deployed in the Basque Country within the European CareWell project, to best respond to the complex needs of multi-morbid patients. Our statistical analysis carried out in Donostialdea County has demonstrated that the profile of resource consumption has not shown the expected changes. The fact that no significant differences were found indicates that the aim of maintaining stability in multi-morbid patients has not been achieved. However, this is just a static view of the situation two years after the initial deployment. Although necessary, this information is not enough to assess the efficacy of the intervention since the way in which health care is organized is considered as a unitary actor, either adapting to the environment or remaining inert. Integration of health care requires the alteration of delivery processes that change over time in predictable and unpredictable ways. Some processes may be altered more quickly than others, depending on how long it takes for the health-care staff to achieve the necessary behavioural changes. The objective of this work was to apply predictive modeling adapted to the local context to develop a tool within the Deming’s plan-do-check-act (PDCA) cycle to manage continuous improvement in integrated interventions over the long term in the CareWell project.