Health and Social Care Innovation and Technology
Adherence to treatment remains an unresolved issue. According to data from the World Health Organisation (WHO), the figures in developed countries are around 50%, with a drastic reduction in developing areas. Poor adherence to treatment has important socio health and economic consequences:
We approached the project with a twofold objective: to create a programme that would provide added value to our client’s service and to generate a beneficial impact on the health of patients and their families.
The service was designed by a multidisciplinary team with experience in clinical and psychosocial work in collaboration with our client. In addition to this service, a technological solution was designed and subsequently developed and implemented for the programme. The result was a comprehensive approach rolled out in 4 phases:
Patients who accepted the service were assessed on clinical and psychosocial factors according to their pathology with approved tests related to (SDH) social determinants of health, (AT) adherence to treatment in routine clinical practice and (HRQoL) health-related quality of life, establishing a risk level for each patient.
The health education plan is chosen based on the level of risk, which is discussed with each patient or carer. The patient is accompanied, oriented towards adhering to treatment, self-care, healthy lifestyles, mental and family health, with a number of activities undertaken over a period of time with a multidisciplinary team.
The action plan agreed with the patient or carer is put into play, including monitoring, accompaniment and detection of early warnings to identify risks and proper coordination with the health facility through Real World Data.
The specific socio-health indicators for each pathology are analysed and the tests for measuring adherence to treatment are carried out again to generate a holistic assessment of the patient and to be able to determine the results of the programme which are delivered to clients using business intelligence tools based on real evidence (real world evidence).
In the first 24 months of the programme, over 45,000 people were cared for, and a total of over 300,000 interventions were carried out, contributing to the generation of positive results for patients, families and health institutions.
Glycosylated haemoglobin - Pop. with a diagnosis of diabetes mellitus: 11% of patients with a diabetes mellitus diagnosis who did not meet the clinical glycosylated haemoglobin target of 7% were moved to adherent status. Likewise, 32% of patients who did not meet the clinical target with ranges between 7.1% and 15% saw significant reductions in glycosylated haemoglobin levels.
MAP (Mean Arterial Pressure) Pop. with mixed diagnosis of diabetes mellitus and hypertension: 15% of patients with a concomitant diagnosis of diabetes mellitus and essential hypertension showed positive changes in MAP figures that allowed them to meet clinical targets, while 21% of patients showed positive changes in MAP figures.
Overall, 91% of people who completed the programme maintained or improved their psychosocial risk classification, of which 30% showed a positive change from their initial CRPS. 9% show a negative trend or change in risk.
Risk management through early warnings: In the 80% of people who completed the programme with the same or improved results, clinical and psychosocial risk factors were identified, mitigated and prevented through early warnings.
Those who tended to have the same or improved results presented a higher number of warnings due to their health education on issues related to knowledge of the underlying pathology, as well as warning signs and symptoms.
We identified that patients with a negative trend had fewer records of early warnings, especially those related to adhering to treatment and attending check-ups, compared to patients who remained the same and those who improved.
The innovative nature of the programme has brought clear benefits in terms of patient health, promotion of healthy habits and reduction of related costs. The success of the approach and its functioning suggest that it is highly scalable and could be replicated in other types of programmes, not only for cerebrovascular pathologies but also for mental, orphan and non-chronic diseases or for post-operative monitoring and follow-up.