Advanced mobile solution in a continuum of care process

摘要

Introduction : Osona is a Catalonian county with almost 157.000 inhabitants, of which 2.9% are 85 years old or over, and it behaves like a micro health and social system in the Catalan territory. The health providers and the local administrations who are responsible for community social services, have made a strategic alliance, that seek to create a more integrated and person-centred care of persons with complex health and social care needs, based government guidelines for Programs of Prevention and Care of Chronic Patients (PPAC) and Social and Health Interaction (PIAISS). The home care of people with dependence in Osona has integrated and a new care model based in interventions adapted to their needs has been developed. The Fundació Assistencial d'Osona (FADO), that is a nonprofit foundation, is the responsible for the home care in the county, serving more than 750 people each year. Often people with complex health and social care needs require the intervention of multiple suppliers, therefore the challenge is to achieve shared care for this group and the accessibility to information is a key element for advancing. In order to have updated information from users, as well as the monitoring of personalized care plan, objectives and tasks involved, we designed a system of interconnected with the FADO central server through mobile network to enable remote control and the exchange of information, which automates and streamlines processes for data collection. The aim of the communication is to describe the follow-up model of the users through the mobile platform. The project has passed the trail period and will be implemented in April 2016. Development of the project : Some months ago we launched the new service ASSISCAT platform, a mobile application jointly developed with Vodafone that the FADO workforce would have access through their Smartphone in the home visits. By means of this application they would be able to consult the care plan for each user, the services they require (personal care and showers, support in daily activities, mobilizations...), record notes concerning their state, autonomy degree, and personal choices or manage any incident that should occur. This application will provide a higher quality service, greater security and continuity of care, in order to contribute in the improvement of their health and wellbeing. This application will also help the professionals to organize in a better way and keep a detailed control of their daily activity, from registering the arrival and departure time of each visit, validate the completion of scheduled tasks, consult the schedule for the next days and location through GPS the best route to reach the addresses. It also allows a secure messaging system. This application is based in a machine to machine connection system that links directly mobile devices to the FADO server, which allows you to connect directly with the patient electronic health record. So the information is always updated avoiding the conventional network ensuring as well data protection. Moreover each mobile device is provided with a card connected through roaming (global SIM), in order to increase the coverage level. The indicators for the evaluation of their impact are related to the care plan optimization, the improve of the experience and security of the patient and the service efficiency. Conclusions : We present an advanced mobile solution to ensure access to information and increase the safety of users. We also present results of efficiency improvements with the use of this technology.