Multipronged management strategy for patients with complex needs using an integrated organizational model

Introduction: The Basque healthcare system is facing an overwhelming problem due to chronicity and an aging population. In our setting (San Sebastian, Gipuzkoa province, Basque Country) more than 25% of the population (400,000) will be over 65 years old in the next decade out of which 10,000 people...

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Bibliographic Details
Published in:International journal of integrated care 2018-10, Vol.18 (s2), p.14
Main Authors: Zubeltzu, Beñat, Mitxelena, Asier, Alberdi, Ander, Elola, Maitane, Errasti, Uxue, Berroeta, Ander, Vaquero, Marta, Fuertes, Ana, Perez, Naiara, Echegaray, Miguel, Huertas, Isabel, Emparanza, Jose Ignacio, Basabe, Iban, Belastegi, Ana, Goicoechea, Xabier, Agirre, Cristina, Alvarez, Maite
Format: Article
Language:English
Subjects:
Call centers
Case management
Chronic obstructive pulmonary disease
Comparative studies
Complex patients
Economic impact
Emergency medical care
Emergency medical services
Evidence-based nursing
Health care
Hospitals
Internal medicine
Length of stay
Nursing homes
Primary care
Quality of life
Training
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Summary:Introduction: The Basque healthcare system is facing an overwhelming problem due to chronicity and an aging population. In our setting (San Sebastian, Gipuzkoa province, Basque Country) more than 25% of the population (400,000) will be over 65 years old in the next decade out of which 10,000 people will be multi-pathological. Traditionally, these patients have been managed without a coordinated strategy, leading to multiple hospital admissions, patient discomfort and a large economic impact.Description of practice change implemented: A multipronged management strategy for patients with complex needs using an integrated organizational model that included liaison nurse, call center and new technologies (web/ app-based monitoring).Aim: Improving quality of life and perceived quality of health assistanceTraining patients and healthcare providersReducing length of stay and Emergency Department (ED) visitsRespecting patients’ will on intensity of treatment and place of care provisionTarget population:- Multi-pathological patients with high readmission rates- Home-dependent patients- Nursing home residents- End of life patientsTimeline:2003: New Evidence-based practice unit started within Internal Medicine Dpt.2005: Prediction rule development and validation for readmission risk2006: Before and after study with a multipronged strategy (PAMI) targeting patients with high readmission rates.2009: Creation of a management unit for chronic patients.2010: Comparative study of telemedicine vs PAMI2010: Cluster randomized clinical trial of PAMI in nursing homes2012: Creation of a diabetes pathway2012: Creation of an integrated health organization (OSI)Highlights:- Development of a single electronic medical record- Stratification of the population and tagging of chronic patients.- Conciliation of treatment with an e-prescription tool.- Conciliation of information (hospital/primary care meetings, communication tools)- Case management of complex patients (PAMI programme) with process-specific questionnaires, liaison nurse, call center and web/app monitoring activating changes in prescription, GP appointments or direct hospital admission. With 4,200 patients followed within this programme, we have achieved 30-50% of direct admissions (avoiding ED visit). Days spent at the hospital were reduced by 25% for nursing home residents, 55% for home-dependents, 58% for heart failure patients, and 25% for patients with COPD. The number of ED visits made by each group was also reduced
ISSN:1568-4156
1568-4156
DOI:10.5334/ijic.s2014