Dr. Elisa Tarazona
Health Care Organisation manager
Salvador Sanchis
HR Director
Carlos Catalán
Medical Director
Manuel Bosch
Deputy Director of Strategy and Development
The Alzira Model
The experience of Ribera Salud
Hospital de la Ribera, Alzira (Valencia)
October 6th, 2015
Summary
An Integration Model
 Clinical management
 HR Strategy
 Technological development
Results
Surveys
About Ribera Salud. Leading a process of change
Conclusions.
THE RIBERA SALUD MODEL
Key Ideas
PPP Model
Capitated
Payment
Healthcare
Integration
Networking
AN INTEGRATION MODEL
The Evolution of our
Health Model Approach
The Evolution Of Our
Health Model Approach
The Evolution of Our
Health Model Approach
The Patient Today
ACUTE
PATIENT
P
A
T
I
E
N
T
PRIMARY
CARE
HOSPITAL
HLME
OLD PEOPLE’S
HOME
CHRONIC
PATIENT
PRIMARY CARE
HOSPITAL
HLME
OLD PEOPLE’S HOME
P
A
T
I
E
N
T
The Integration Model
Capitative payment ….
Objective:
“To achieve the best health conditions for the citizens”
StrategIc tool : healthcare Integration
Most importantly: cultural change of the politician and healthcare organization
managers.
 The most important thing is not the hospital.
 What really matters is to stand by the whole healthcare network, its professionals
and other agents involved (City Councils, Schools, Nursing homes, old people’s
homes, etc)
 To create a corporate culture: Population Health Management
P R O A C T I V I T Y
Integrated Primary Care Center - SUECA
Integrated Primary Care Center - SUECA
Triangle for Success
1 Clinical Management:
To achive stronger
professionals´comitment in
decision-making processes.
Do the correct in the best palce
with the best quality &Efficiency
Chronic Health Plan.
Proactivity in Care
Home care, social and
healthcare network.
Patient Safety
. Demand Management
Citizen
Patient
HR
Care
Giver
IT
2 - People
Management:
Training financed by the
Organization, Teaching
(University and MIR) and
Research
Incentives system.
Career and professional
development
Information Technologies:
Full EMR (all departments and levels integrated)
Relationship doctors-patients (Health Portal)
Relationship betwen profesional (hospital-Primary Care)t.
Business Intelligence System (from professional to corporate
manager).
Benchmarking. Cost analytics and what-if capabilities.
Clinical Management
Objective: Achieving a stronger professionals’ commitment
in decision-making processes
1 Population Healthcare Management:
Proactivity
• To promote preventive and health
promotion activities
• To be proactive in patient’s care
• Healthcare management of demand
and needs
• Challenge: Chronic Diseases
Management
• Segmentation of population
2 Professional Alignment: Primary Care
Doctor – Hospital Doctor
3 Nurses: new roles, competences and
responsibility: emergency triage case
history management, etc.
5 Variability decrease in clinical practice
• Healthcare processes, Medical paths
• High resolution
6 Healthcare continuity
• Care longitudinally
• IT integration
7 Management of Demand vs Needs
Self management tools
• Health website
• Florence Direct. To know “all” about your
patient
• Inter-consultation
• Algorithms; Specialist Consultant (link doctor)
• Predictive models
4 Health objectives alignment across
the whole organization
Best Quality & Efficiency
Kaiser Pyramid of Care
Right Process, Right Moment,
Right Location, Right Risk
RISK
ADJUSTMENT
•
•
•
Risk adjustment
tools
CRGs
Predictive Models
CARE
PROVISION
•
•
•
•
•
•
•
EMR
Case management
Decision tools
E-consultation
TeleHealth
Promoting health
PAthways
ANALYTICS
•
•
•
•
Costs per patient
Utilization per patient
Clinical outcomes
Outcomes that
matters to patients
Complexity
CRG
+
Segmentation Project
and Cost per Citizen
Good
Control
Opportunities
for efficiency
-
Healthy
population
Case
Management
-
+ Cost
Health Promotion Plan
Who are we?
We look after citizens’ health,
encourage healthy lifestyles and
strive to offer the best health
care services
Aim
Developing and strengthening the necessary knowledge and tools so that the
population can lead a healthy lifestyle, be it individually or in an organized fashion.
What can we offer?
Our knowledge as health care professionals in conceptualising actions towards
HEALTH PROMOTION and DISEASE PREVENTION
Chronic care plan
+Salud Program
Health talks
Workshops
Information stands
Conferences
Open doors days
Colaboration with institutions
Media
Contests
Pomotional materials
Health Portal
Promotion Campaigns
The health portal includes a module to classify patients that will
automatically show the health promotion campaigns that are best-suited to
each profile.
Other Promotional Activities
Coordination with:
Public Health
•
Identification of citizens: vaccinations, check-ups, cardiovascular risk.
•
Cancer screening : cervical, breast, colon.
Communication: Writing Committee (Magazine, radio/TV spots, brochures,
“Els Ribera” comic, etc.) World Days (AIDS, tobacco, etc.)
Schools: Health education programme
City Hall: Health Days
Social Services: Social and Health Care Programme (senior citizens’ homes)
Pharmacies: Programmes about the proper use of medicines
Chronic Patients Plan:
Levels 1 and 2
Level 1 and 2
Activities carried out by health centre professionals.
Updating algorithms, clinical guidelines, “stop doing to
start doing” procedures.
Leaders responsible for pathologies in each basic area.
Ongoing training, follow-up tools.
Evaluation – feed-back with professionals.
Chronic Patients Plan:
Level 3
Level 3. Case Management
Appointments: Hospital /Home-Care Unit / Primary Health Care / Social
Work.
Case management – responsibility of the Primary Health Care nurse
“Shared” patient Primary Health Care Doctor /Internist /Nurse.
24/7 Call-Center.
Digital clinical history to help continuity of treatment.
Managing new technologies.
Chronic Patients Plan:
Level 3
Chronic Patients Plan:
Level 3
Relationship Between Professionals
PRIMARY CARE - HOSPITAL
HOSPITAL - HOSPITAL
Electronic medical record:
Virtual consultation (no patients)
Electronic medical record:
On-site and virtual consultations
Virtual:
Video conferences, call conferences and
intranet (e-learning) for clinical sessions,
training, etc
Video conferences (healthcare network)
On-site:
• Specialist-consultant
• Rotary training periods in hospital for
family doctors
• Family doctors do shifts in emergency
service.
Interdisciplinary Committee:
• Tumours
• Infections
• Pharmacy and rational use of medicines
• Safety
Health Portal
PRIMARY CARE:
FAMILY DOCTOR AND
NURSE
HOSPITAL:
SPECIALIST AND
CASE MANAGEMENT NURSE
Health Portal
Heath Portal
+ SALUD
External web page
(open access)
HEALTH
PROMOTION
Personal area “My
health e-space”
HEALTH
MANAGEMENT
The health portal “+SALUD”
is a new interactive portal
designed for patients. It is an
online
platform
where
citizens can easily access all
the information regarding
their health and well-being..
Health Portal
Health Portal
The patient access to his/her electronic medical record from anywhere:
- Virtual communication of test and citology results
- Consultation from abroad
- Texting with te primary care nurse and family doctor
Follow up and monitoring:
- Cardiovascular risk factors
- Diabetes mellitus type 1 and 2
- COPD
Telemonitoring:
- Cardiac insufficiency
- COPD
- Diabetes mellitus type 1 and 2
Health Portal
Patients with special needs:
Oncology patients in treatment with chemotherapy: family doctor and
primary care nurse, oncologyst and case management nurse.
Patients with inflamatory rheumatologic deseases in treatment with
biological therapies: family doctor, rheumatologist and case management
nurse.
Patients carrying ostomy: family doctor, primary care nurse and case
management nurse.
H.R. Strategy
Private employees
Diversity Management
Financed by the
organization
Government’s old employees
Hospitals with MIR (Resident Medical
Intern) and University accreditation
; Professionals as University teachers.
Civil Servants
District Council’s employees
research projects and
performance of clinical trials
PRIVATE
EMPLOYEES
Flexible incentive
plan
Personalized compensation, “flexible incentive schemes ”
PUBLIC
SERVANTS
Variable salary
Fix salary
Variable salary
Fix salary
Quantitative work
objetives
Variable salary depending
on activity and aims
achieved by the
professional.
Qualitative work objetives
Healthcare quality and
efficiency criteria: mean stay,
readmission rate…
Retribution based on post and professional´s development:
training and experience retribution basis
FUNCTIONAL
INTEGRATION
Incentive System
OBJECTIVES
STANDARDIZE
ALIGNMENT
SIMPLIFY
ADJUSTMENT
FOSTER
CONCEPT AND
WEIGHTING SYSTEM
. Common strategic lines
. Criteria for each professional
category
. Organization’s aims
. Healthcare administration
. Valuation criteria
. To economic and social
situation
. Teamwork
. Motivation
. Commitment
[Ebitda (Earnings before Interest, Taxes, Depreciation and Amortization)
Public Healthcare Authority Objective Plan (annual ranking between 24 health depts. that
features 35 indicators related to health provision, published by the Regional Health Ministry).]
Incentive System
Concept and weighting system
80%
according to
occupational
categories
100%
Target.
Different per
category
20%
for all employees:
Ebitda, Objective
Plan, Joint
Commission,
Chronic Plan
Incentive System
Specialized care, Associate Doctor
Successive/first consultations ratio
Tests/first consultations ratio
First visit delay/waiting times
Tests delay/waiting times
DRG case adjusted average stay
DRG case adjusted tests/admission
Surgery waiting list0
Incentive System
Primary Care, Associate Doctor
Centre’s balance sheet
Expenditure
Ascribed population
HR cost
Referrals to hospital
units
GFAR - efficient and effective
prescription
Vaccination coverage
Health e-Space
Remunerative System
Results and Conclusions
Results
Personnel costs represents 45-50% of the company’s total expenditure
Bonus remuneration amounts to 20% of personnel total expenditure. For the doctors
category it can reach up to 35-40%
Last year, meeting of objectives averaged 94%
Conclusions
Adjustment: the variable system allows personnel costs to be adapted to the organization’s
outcomes and the quality of service we deliver.
Equitative: it recompenses the best and hardest workers in the organization.
Commitment: it fosters the development and long-term commitment of people within the
organization.
Balance: it aids tailoring the staff to real activity. The bigger the team, the lower individual
variable remunerations are.
Our incentives system is a key factor in talent attraction.
Technological Development
For
the Citizen
•
•
•
•
•
SMS notice
Touch screen
Emergency waiting time
Simultaneous translation
Family patient information
For
the Professional
•
•
•
•
Electronic medical history
and digital radiology
Integrated processes.
“Florence directo”
Medical History access from
mobile phone
Telemedicine. Teleworking
in radiology
For
the Manager
• Quality evaluation
• Emergency response time
• Services and professionals
workloads
• Technology and
management
• Systems innovation
Ribera Salud tools
Support for Professionals
Online access from the nursing homes
•
•
•
•
•
•
•
•
Hospital’s admissions-appointment module
(Florence)
External consultation proposals
Test requests
Consultation without patient referrals
Algorithms
Florence direct: automated information system
Hospital discharge. Online history
Pharmacy and medical material attribution
•
•
•
•
•
Access to SIA Abucasis from Florence
Registration of all vaccinations in RVN
MPRE module for consultations and prescriptions:
(emergency room, external consultations, outpatient surgery, hospitalization…).
IT module, hospital prescriptions
Abucasis agendas used for appointments (emergency
room, pediatrics, hospitalization...). As an agenda
manager (not for citizen)
Social and health centres, (homes of residence)
Inspection: Electronic visa, IT follow-up
Public Health
General Idea– APLICATIONS (CAV))
Consellerí
a
Intranet Corporativa
SIP
Estadística y Gestión
(Cognos)
Costes
Reporting
Iasist
Portal del Ciudadano
CMI
Gestión Asistencial ( Florence)
Ofimática
Cardiología
(Philips)
Nefrología
(Nefrolink)
Gestión
Áreas Críticas
(Drager)
Gestión
RR.HH
(Meta4)
Laboratorios
(Unilabas)
Gestión
Económica y
Logística
(Navision)
PACS (Carestream
Philips)
Clínico
SIAAbucasis
GAIA
LabOnline
SIDO
RCLE
…
CMBD
ACTIQUI
Office
Correo
Impresión
Comunicación
SISAL
Sistemas de Base (Windows XP/7)
COMPAS
Comunicaciones
HEAVS
Propuestas CCEE
Florence Directo
Interconsultas
Florence Gestión
Emergency Activity
Hospital
Primary and
Hospital
Care
integration
Primary Care
Hospital
Emergency
Distribution
Hospital/
Primary Care
Source: Ribera Salud
Demand Management
Results
Number of PC referrals to specialties related
to the orthopedic and trauma service
Referrals (left axis)
Inter consultations (right axis)
Source: Ribera Salud. Data from Vinalopó Hospital
Demand Management
Results
Evolution of orthopedic and trauma surgery activity
(1st consultations)
TRAUMA
REHABILITATION
RHEUMATOLOGY
Vinalopó Hospital
Demand Management
Results
Referrals from PC to specialities.
Utilization rate per 1,000 inhabitants
Vinalopó Hospital
Waiting lists
Results
Surgical
waiting
list
in 2014
Lista
de espera quirúrgica
(días de
espera)
100
90
80
70
60
50
40
30
20
10
0
(in days)
SNS
90
CV
66
Specialized
waiting
list
Lista
de espera consultas
especialista
(díasinde2014
espera)
(in days)
60
SNS
53
50
CV
41
40
30
20
10
52
39
32
32
0
Alzira
Torrevieja
Denia
Vinalopó
18
31
28
29
Alzira
Torrevieja
Denia
Vinalopó
Source: Conselleria de Sanitat (Alumbra 2014). National Benchmark: Indicadores Clave del SNS: INCLASS 2015”
Average
complexity (DRG) per age group
Complejidad media (peso GRD) global y por grupo de edad
3,00
2,10
2,50
2,00
2,00
1,90
1,50
1,80
Peso medio por hospital
Complexity
Results
Vinalopo; 2,03
Torrevieja; 1,86
1,00
1,70
0,50
1,60
0,00
1,50
0-4 AÑOS
5-14 AÑOS 15-44 AÑOS 45-64 AÑOS 65-74 AÑOS
<75 AÑOS
Average weight (in red RS concessions, in black Spanish
benchmark) per age group. Source: RS MBDS, Spanish
benchmark from DRG Ministry of Health 2013 database.
Denia; 1,78
España; 1,74
GrossAlzira;
and
adjusted mortality rate
1,66
1
Gross mortality rate (left axis)
Adjusted mortality rate (right axis)
Number of bypasses
Número de Bypass
Valve surgery
50
100
150
Mortality in Bypass and Valve Surgery 2014.
Source: BMSD of 29 hospitals. Elaborated by IASIST
0
20
40
60
80
100
120
140
160
180
200
220
Number of bypasses. Source: BMSD of 29 hospitals. Elaborated by IASIST.
Satisfaction Survey
Global satisfaction
Primary
Satisfacción
global en la atenciónin
primaria
2014 care in 2014
Satisfacción satisfaction
global en la atención in
hospitalaria
2014 care in 2014 Sa
Global
Hospital
Vinalopó 8,0
Vinalopó 9,0
Denia 7,7
Denia 8,7
Torrevieja 7,8
Torrevieja 8,6
0
Alzira 8,6
CV 7,8
Alzira 7,8
2
4
6
8
T
10
0
CV 8,5
2
4
6
8
10
Source: Conselleria de Sanitat 2014
Chronic Patient Plan
Results
Fuente: Brookings
“Spain: Global Accountable Care in Action”
Satisfaction Survey
91% of the patients show their satisfaction with
the health care provided.
94% do not know the Alzira Model.
Work Environment Survey
93% of our employees recommend Ribera Salud centers as a place to work in.
84% consider that the organization provides the required information to do their job in
optimal conditions.
The pride in belonging to this Group is the most highly rated indicator. 8 out of 10
employees are satisfied or highly satisfied.
What our employees consider the most important aspects in our Organization is:
• Career development
• Respect and courtesy to the patient
• Good working atmosphere
• Ackknowlegement of the work carried out
All surveys “Best Place to Work” (credibility, respect, impartiality, pride and fellowship)
show that our indicators are over the average in healthcare sector.
90% of our employees consider they are contributing in a positive way to the society
welfare, 6 points over the average in the healthcare sector.
Health Department Evaluation
COMPARATIVA
COMPARATIVA
CONCESIONES
CONCESIONES
2011
2011
INDICADOR INDICADOR
Posición ,,,
8,00 ,,,
Posición
Valor …
81,16
Valor …
RIBERA
Tema
Valor
Tema
8,00
4
84,22
81,16
TORREVIEJA
RIBERA
Valor
Valor
54
82,91
84,22
10
5
80,10
82,91
TORREVIEJA
DENIA
MANISES
DENIA
Valor
Valor
Valor
Valor
10
6
82,86
80,10
6
82,86
VINALOPÓ
MANISES
VINALOPÓ
Valor
Valor
Valor
Prestar atención
Prestar
sanitaria
atención
quesanitaria
responda
que
a las
responda
expectativas
a las expectativas
de la población.
de la población.
Satisfacción: Prestar
Satisfacción:
atenciónPrestar
sanitaria
atención
que responda
sanitariaaque
las expectativas
responda a las
deexpectativas
la población.de la población.
Calidad
Calidad
97,58%
98,45%
97,58%
98,85%
98,45%
94,49%
98,85%
92,67%
94,49%
92,67%
2. Índice de calidad
2. Índice
de lade
información.
calidad de la información.
Calidad
Calidad
3. Índice de percepción
3. Índicede
demejora.
percepción de mejora.
Calidad
Calidad
97,05%
86,97%
95,10%
97,05%
93,09%
86,97%
95,75%
95,10%
100,00%
93,09%
95,23%
95,75%
100,00%
89,00%
89,57%
95,23%
96,11%
89,00%
89,57%
96,11%
92,59%
30,67%
25,44%
65,60%
34,91%
97,17%
81,59%
1,17%
3,31%
38,24%
100,00%
94,48%
100,00%
93,49%
80,09%
92,59%
39,81%
30,67%
39,84%
25,44%
62,94%
65,60%
48,62%
34,91%
93,52%
97,17%
77,28%
81,59%
4,84%
1,17%
4,09%
3,31%
44,23%
38,24%
100,00%
94,48%
100,00%
93,49%
92,13%
80,09%
30,46%
39,81%
25,17%
39,84%
45,15%
62,94%
30,91%
48,62%
95,19%
93,52%
71,01%
77,28%
0,07%
4,84%
1,56%
4,09%
33,86%
44,23%
100,00%
99,06%
100,00%
100,00%
92,28%
92,13%
33,04%
30,46%
27,84%
25,17%
70,47%
45,15%
35,75%
30,91%
96,47%
95,19%
80,02%
71,01%
1,86%
0,07%
3,01%
1,56%
38,95%
33,86%
97,23%
99,06%
100,00%
100,00%
91,82%
92,28%
34,41%
33,04%
33,23%
27,84%
55,82%
70,47%
33,03%
35,75%
95,81%
96,47%
86,19%
80,02%
4,11%
1,86%
4,00%
3,01%
44,75%
38,95%
97,23%
100,00%
91,82%
34,41%
33,23%
55,82%
33,03%
95,81%
86,19%
4,11%
4,00%
44,75%
72,12%
65,73%
2,11%
43,23%
72,12%
38,75%
65,73%
5,09%
2,11%
44,49%
43,23%
47,18%
38,75%
0,84%
5,09%
69,35%
44,49%
49,66%
47,18%
2,28%
0,84%
71,17%
69,35%
59,95%
49,66%
6,81%
2,28%
71,17%
59,95%
6,81%
1. Índice sintético
1. Índice
de satisfacción.
sintético de satisfacción.
Ciudadanos: Generar
Ciudadanos:
confianza
Generar
y seguridad
confianza
en el
y seguridad
sistema. en el sistema.
Ciudadanos: Generar
Ciudadanos:
confianza
Generar
y seguridad
confianza
en el
y seguridad
sistema. en el sistema.
Penalización OE.3Penalización
Ciudadanos:
OE.3Generar
Ciudadanos:
confianza
Generar
y seguridad
confianza
en el
y seguridad
sistema en Penalizaciones
el sistema
Penalizaciones
Promover la salud
Promover la salud
4. Indicador de4.Cobertura
Indicador
vacunal
de Cobertura
de poliovacunal
a los 6 de
meses.
polio a los 6 meses.
Salud Pública
Salud Pública100,00%
5. Indicador de5.Cobertura
Indicador
vacunal
de Cobertura
de Triple
vacunal
Vírica de
a los
Triple
15 meses.
Vírica a los 15 meses.
Salud Pública
Salud Pública100,00%
6. Indicador de6.Cobertura
Indicador
vacunal
de Cobertura
DTP a los
vacunal
18 meses.
DTP a los 18 meses.
Salud Pública
Salud Pública
7. Cribado de 7.
HTACribado
de riesgo
deelevado
HTA de riesgo elevado
Salud Pública
Salud Pública
8. Control de hipertensión
8. Control de hipertensión
Salud Pública
Salud Pública
9. Indicador de9.Cribado
Indicador
de diabetes.
de Cribado de diabetes.
Salud Pública
Salud Pública
10. Control de diabetes
10. Control de diabetes
Salud Pública
Salud Pública
11. Calidad en el
11.Seguimiento
Calidad en el
delSeguimiento
Embarazo endel
Atención
Embarazo
Primaria.
en Atención Primaria.
Salud Pública
Salud Pública
12. Niños con examen
12. Niños
de con
salud
examen
completo
de salud
en SIAcompleto
por Atención
en SIA
Primaria.
por Atención Primaria.
Salud Pública
Salud Pública
13. Valoración 13.
del riesgo
Valoración
vascular
del riesgo vascular
Seguridad
Seguridad
14. Indicador de14.abandono
Indicador
tabáquico
de abandono
en pacientes
tabáquico
deen
alto
pacientes
riesgo de alto riesgo
Salud Pública
Salud Pública
15. Indicador de15.registro
Indicador
del Índice
de registro
de Masa
del Índice
Corporal
de Masa Corporal
Salud Pública
Salud Pública
16. Pacientes con
16. diagnóstico
Pacientes con
correcto
diagnóstico
de EPOC
correcto de EPOC
Seguridad
Seguridad
17. Seguimiento
17.delSeguimiento
puerperio del puerperio
Registro AP
Registro AP
18. Indicador de18.cobertura
Indicador
vacunal
de cobertura
del VPHvacunal del VPH
Salud Pública
Salud Pública
19. Indicador de19.cobertura
Indicador
vacunal
de cobertura
del virus
vacunal
de la gripe
del virus de la gripe
Salud Pública
Salud Pública
20. Cribado de 20.
tabaquismo
Cribado de tabaquismo
Salud Pública
Salud Pública
Penalización OE.3Penalización
PromoverOE.3la salud
Promover
- Vacunaciones
la salud - Vacunaciones
Penalizaciones
Penalizaciones
Penalización OE.3Penalización
PromoverOE.3la salud
Promover
- Niño ylaembarazo
salud - Niño y embarazo
Penalizaciones
Penalizaciones
About RIBERA SALUD
What We Do
More than…
1,500 scientific publications and 600 research projects
100 National and International Awards
350 National and International Conferences (World Bank, BID etc…)
6,000 professionals
500 doctors trained
3,000 Healthy Activities (Promotion Plans)
700 Million € committed investment
30 Quality Certifications
And…
Visits from more than 100 countries (Governments, Universities,
Institutions)
Leading a
Process of Change
RIBERA SALUD…
Is the only Spanish Company exclusively dedicated to the Administrative Concessions in healthcare
sector.
Torrevieja Hospital developed FLORENCE (electronic clinical history), which was implemented in 15
Hospitals in Chile.
Torrevieja and Vinalopó Hospitals have implemented a shared services system to foster the multihospital vision.
Has implemented an interactive health portal Patients/professionals.
First project of patients segmentation according to the risk level.
Alzira Model…
Is the first project with a per capita finance system, whose objective is the health promotion.
Establishment of Integrated Healthcare Centers (CSI), joining Primary Care and technology to
Specialized Care.
Is the first PPP considered as a case study by Harvard University.
Alzira Hospital, first public hospital…
In Spain with electronic clinical history and digital radiology (1997).
In Spain with individual rooms and a bed for the companion (1997).
That developed an integration model Hospital /Primary Care.
Committed to CSR Alzira Hospital, first public hospital in Spain with sign Language Interpreter (1997).
The Expansion of the Alzira Model
Where we are
In Spain
In Latin America
“Florence” software in 15 public hospitals
in Chile, 3 in Uruguay and 2 clinics in
Honduras
Where we are
Hospital del Vinalopó
Elche-Alicante
www.riberasalud.com
www.albertoderosa.com
www.modeloalzira.com
@riberasalud