Setting up a comprehensive management model for chronic conditions/Puesta en marcha de un modelo de gestión integral de procesos crónicos

The ‘Valencia-La Fe’ Department of Health has launched a comprehensive management model for chronic diseases in order to introduce innovations in the care for these patients, identifying and stratifying their catchment population (Kaiser Permanente model), at the same time as ensuring continuity of care through appropriate coordination and integration of services across the different levels of care.


Introduction
Nowadays, the management of chronic conditions is one of the greatest challenges facing health systems. The current model of care involves one-off contact with chronic patients when their condition worsens, and they remain invisible to the system until subsequent exacerbations.
The 'Valencia-La Fe' Department of Health has launched a comprehensive management model for chronic diseases in order to introduce innovations in the care for these patients, identifying and stratifying their catchment population (Kaiser Permanente model), at the same time as ensuring continuity of care through appropriate coordination and integration of services across the different levels of care.
The aim of the project is to provide comprehensive, proactive, appropriate and safe care to patients with complex chronic conditions who require continuous monitoring. The achievement of this objective relies on strengthening the continuity of care through the structured coordination of care and social resources, promoting health education for patients and their caregivers, and adopting new technologies to ensure that their needs are met. It allows health outcomes and quality of life to be improved through ensuring early detection of exacerbations; providing emotional support for and communication with patients and caregivers; and enhancing prevention measures, health education and self-care. Further, at the end of life, a dignified death should be supported by coordinating and using efficiently the broad range of resources required for the provision of care in the final stages [1][2][3][4][5].
The Primary Healthcare Team is the key player for the management of most chronic patients. A new role has been created in the Department of Health: the nurse case manager (NCM) who coordinates care and undertakes the monitoring of complex chronic patients at a distance. The relationship between primary care doctors and specialists has been strengthened. Protocols, care pathways and guidelines for action have been developed by consensus between experts based on the scientific evidence available [6][7][8][9].

Description of the project:
Inclusion criteria: based on a list obtained from hospital databases of adults in the catchment area of the Valencia-La Fe Department of Health, the population was stratified and level 3 patients identified (that is, patients with chronic diseases and two or more emergency admissions to the hospital in the previous year) [10].

Patient and caregiver information • •
: general practitioners (GPs) contact patients and/or their caregivers to tell them about the care programme inviting them to participate and requesting their consent. For those who agree, details of their case (patient personal data and contact telephone numbers) are submitted to the Hospital at Home (HAH) Service and to the nurse case manager. In the case of patients who are hospitalised, the HAH doctor is responsible for their recruitment [11]. to-date medical report, incorporating the nursing reports, and requests a social report, if required. The discharge report should also include the diagnosis code (ICD-9). A copy of this medical report is given to the patient and/or caregiver [12,13]. Scheduled Remote Monitoring:

Education and Secondary Prevention
the NCM confirms the inclusion of patients on the follow-up programme, updates the nursing data on discharge from the ESPP and checks the HAH doctor's records. The telephone calls with patients and/or caregivers are scheduled, adjusting the frequency of contact in response to changes in patient condition. The NCM also assesses whether objectives are • • met, reviews and updates the care plan, and adjusts treatment. Records should be kept of all telephone calls. If unforeseen changes are required, the patient's GP is contacted. Depending on the level of social risk perceived by the social worker, it may also be necessary to coordinate healthcare and social services. Lastly, any healthcare equipment under long-term use at home (such as that for oxygen or aerosol therapy) and orthotic and prosthetic devices should be regularly checked [14][15][16]. Follow-up of the patient in primary care by • • nurses and doctors: the frequency of visits should be adjusted in response to changes in patient condition. If clinical worsening arises and a patient meets the criteria for referral, the primary healthcare team should get in touch with the NCM to arrange transfer to another care provider (HAH, acute care hospital, etc.). The care plan is modified in collaboration with the case manager and data are entered onto the corresponding databases [14,17]. Self-care: patients monitor their own vital signs, modify their behaviour and manage their medication [18][19][20]. Scheduled appointments with specialists: • • these are provided by HAH doctors for cases with a high level of dependence in activities of daily living (Barthel Index <60) who are unable to attend appointments in a doctor's consultation room. Care on demand: the NCM handles any problems that arise over the telephone or arranges for the necessary referral.

Results
From 2010 until May of 2011, 166 patients were included on the follow-up programme and of these 85 died during the study period (55 of them at home and 30 in hospital).
The amount of resources used has been reduced: the number of admissions fell from 258 (during the year before to inclusion in the programme) to 74 (during the case management period); and, similarly, the length of stay, hospital bed days falling from 2346 (prior to inclusion) to 470 (under case management).
After the assessment of the initial data, we propose to adopt the following indicators for the monitoring programme:

Conclusions
A multidisciplinary approach should be used for the care of complex chronic patients.

Introducción
El manejo de las condiciones crónicas es uno de los grandes retos a los que se enfrentan los sistemas de salud. El modelo de atención actual mantiene un contacto puntual con los pacientes crónicos cuando su estado empeora, desapareciendo del sistema hasta una nueva descompensación.
It is important to identify non-cancer patients who require palliative care by using tools that assess the risk of death.
Although further research is required, our type of case management programme seems able to reduce the use of hospital resources (in terms of admissions and inpatient bed days), as well as being a cost-effective way to improve patient quality of life.
Es importante la identificación de paciente paliativo no oncológico mediante la utilización de herramienta de detección de riesgo de mortalidad.