Comprehensive care of complex chronic patients in Hospital Plató

摘要

Introduction : Care of chronic disease and, as part of it, care of complex chronic patients (CCPs) is one of the main challenges for our health system. The “2011-2015 Health Plan for Catalonia” establishes a new model for the prevention and care of chronic disease, based on better detection of patients and on a transversal, multidisciplinary care model. Complex chronic patients in Catalonia are defined as patients with the combination of comorbidity criteria, a record of use of resources and risk criteria. Hospital Plató has a catchment population of 143,000 inhabitants. It is estimated that complex chronic patients represent between 3.5% and 5% of the population, meaning that the target population is estimated to be between 5,000 and 7,150 patients. In our centre, a Comprehensive Care Model for CCPs and patients with Advanced Chronic Disease centered on the process was established in 2012. The stages of the project were carefully designed. Description : In the development of the comprehensive care plan for complex chronic patients the following actions were carried out: - Constitution of the Reference Group in Care to Patients with advanced diseases and palliative needs. - Creation and appointment of the position of the Case Manager Nurse. - Constitution of the Territorial Complex Chronic Patient Project Group. - Preparation and design of the territorial care routes for Heart Failure and Chronic Obstructive Pulmonary Disease. - Internal training by the Reference Group in Care to Complex Chronic Patients, with the methodological support of the Qualy Observatory. - Training stays at other hospitals by the professionals belonging to the Reference Group in Care to Complex Chronic Patients. - Identification of CCPs by markers in the Shared Medical Record of Catalonia, accessible to all the health professionals in the community, in Primary Health Care as well as Hospital Care. - Design of two operational objectives as part of the Hospital's Strategic Plan: o To consolidate the internal and territorial actions of Complex Chronic Patients o A study to create a Complex Chronic Patient Unit This latter objective culminated with the creation of the Complex Chronic Patient Unit in 2014, with 12 beds, which has led to the sectorising of these patients. The objectives of the unit are to improve the health results, maintain the quality of life and at the same time decrease high-cost services such as urgent hospital admissions, maintaining the continuum of care. With this objective in mind, attendance at the daily multidisciplinary meeting by the Case Management Nurse, the social worker, the pharmacist and, since May 2015, by the Case Management Nurse in Primary Health Care was planned, in addition to the complete care team of the unit. Results : Patients dealt with at the CCP units since its creation to date: - By the Case Management Nurse 612 - By the Social Worker: 235 A study was carried out during a one-year period to compare the health results of these patients with those defined in the Chronicity Prevention and Care Programme with the following results: 421 patients were attended with an average age of 84.91 years (SD 8.94), of whom 56% were women. Health results: - Average stay 7.78 days (standard <12 days), - Rate of readmissions at 30 days 8.31 (standard < 20%), - Return to previous dispositive 68% (standard 70-80%), - Transfer to a partner health centre 11% (standard< 15%), - Death 10.96% (standard < 10%). Conclusions : The comprehensive care given to complex chronic patients requires a continuum of care. It must include all the health professionals both in primary care as well as in hospital care. This approach results in an improvement in the quality of care with good health results when compared to those previously defined.