Integrated Care Pathway and personalised care at the heart of Lombardy Region’s strategy for tackling chronic care: lessons learnt from the CreG (Chronic Related Group) model

Abstract

Lombardy Region launched a three years' plan (2016-2018) for tackling chronic care and frailty through a redesign of the health and social care delivery system that hinges on a population health management (PHM) perspective for programme planning interventions and resources and Integrated Care Pathways (ICPs) for organising the provision of personalised care. The reform strategy relies on the Regional piloting experience with the CReG (Chronic Related Group) model that started in 2011. The latter represents a prospective payment system based on a clinical-risk adjustment model. The model is built on three steps: the classification of diseases, a grouping system, and a bundle tariff accounting for a one-year period of care (including pharmacy and outpatient services). The pilot programme has been managed in the Primary Care setting, through GP-cooperatives with several tools and services (Service Centre) to support care planning activities and the actual implementation of ICPs, based on prospective and flexible Personalized Care Plans (PCP). The paper presents the most significant results of the CReG model, comparing data from the patients' enrolled in 2012 (first year) and in 2015 (latest available), at the population level (chronic cohorts) and at individual one (impacts of PCP and GPs' behaviors). A statistical analysis is performed on quantitative data retrieved from different administrative databases (diagnostic and outpatient services, hospital discharge report, pharmaceutical consumption, PCP register, GP patients' register, Service Centres' activities). The discussion highlights the lessons learnt and the challenges to exploit the CReG model yet to the overall Regional population yet to other settings, like intermediate and acute care, broadening the mean of PCPs, as foreseen by the Regional policy.