Integrating Health Care in Cancer. Our experience in OSI Donostialdea

Abstract

Cancer are more than 100 complex conditions that builds a great challenge for health care systems and proffessionals. In the last years, the reality of cancer has evolved to different situations that we must face adapting the traditionally vertical organizations to the natural flow of cancer process that is horizontal. The major challenge is to organize the network of human and technological resources, available in our setting to achieve the best results. Our integrated model allows to horizontalize the management of health care process. This integration facilitates collaboration between professionals and health care services, teamwork, sharing action protocols and clinical information, all under a single and joint direction, which also leads to a patent optimization of resources and costs. In the Map of Processes of OSI Donostialdea, the care provided to oncologic patients is one of the essential cornestones of the healthcare process. The center of the process is the patient with needs and requirements and our actions are designed, planned, coordinated and developed around them to add value at the end of the process. In our unit IDOH we are widely coordinated with Primary Care we have a general way called "Link Oncology" which includes non presentaial online and presential resources in order to coordinate the resolution of questions about diagnosis, treatment, and monitoring of patients with cancer. We approach our mission from 4 guiding principles: - The first one is Early Diagnosis to be able to provide a better therapeutic option in terms of survival or quality of life: We have designed a project called Minbizi from 2013 to face this aspect. It has been developed for 5 neoplasias 30-40% of the suspicious cases sent from Primary Care are cancer and reach the Tumour Boards from Minbizi fast way reaching optimal times from suspect to diagnosis and suitable treatment. We have also designed a project of Genetic Counselling in Cancer to select high risk families in which we plan a specific way of follow-up. From 400 anual consultations presential or non presential, 23% are susceptible of genetic testing and are considered as high risk families. - Once we have a diagnosis of cancer, we have to provide the suitable treatment for every patient based in interdisciplinar teams estructured Tumour Boards in which each professional adds value with his knowledgement, habilities and experience. We have developed 15 Tumour Boards including reference doctors and nurses who are risponsable to manage the process, not only sharing cases and taking decissions. - We are working in collaboration with tumor registry in collection and analysis of data to obtain health results. We have results survival in five processes breast, lung, kidney, pancreas, colorectal and they are similar to other published data. - The fourth mainstay of our work is the healthcare at the end of the life. From an humanistic point of view, we help with the coordination of the different levels of care in this always harmful situation for patients and families. We will introduce our projects and results in the meeting.