Four years of the primary care-internal medicine continuity of care unit in the health region of Guadalajara/Cuatro años de la Unidad de Continuidad Asistencial Primaria-Interna (UCAPI) en el área sanitaria de Guadalajara

The PCIM CCU was set up in June 2006 from the Department of Internal Medicine at the University Hospital of Guadalajara, reaching out to primary care (PC), with the aim of achieving collaboration and coordination between the two levels of care and avoiding the sense of imposition that can be felt in primary care with regards all that comes from the hospital. To this end, several meetings were held between the medical management for primary care, the coordinators of the various primary care teams and the internists responsible for the PCIM CCU prior to the launch of this pilot project.


Introduction
The Primary Care Internal Medicine Continuity of Care Unit (PCIM CCU) was established to address gaps identified in the care provided for complex chronic patients.

Description of the project
The PCIM CCU was set up in June 2006 from the Department of Internal Medicine at the University Hospital of Guadalajara, reaching out to primary care (PC), with the aim of achieving collaboration and coordination between the two levels of care and avoiding the sense of imposition that can be felt in primary care with regards all that comes from the hospital. To this end, several meetings were held between the medical management for primary care, the coordinators of the various primary care teams and the internists responsible for the PCIM CCU prior to the launch of this pilot project.
The objective of the project was to facilitate continuity of care for patients with complex chronic conditions and those with multiple diseases as well as cases in which diagnosis must not be delayed. The methodology for the project (see Figure 1) was similar to that described in the guidelines "Unidades de Pacientes Pluripatológicos: Estándares y recomendaciones" International Journal of Integrated Care -Volume 12, 29 May -URN:NBN:NL:UI:10-1-112961 / ijic2012-26 -http://www.ijic.org/ [1] published by the Spanish Ministry of Health and Social Policy: namely, a consultant internist is assigned to consistently work with three to four health centres in the Guadalajara Health Region, and he/ she is available on a mobile phone (provided by the health organisation) from 9 am to 7 pm, Monday to Friday, or by email. Additionally, these internists hold sessions in the health centres once a month. The objectives of these consultations are: to solve queries arising when a patient is seen in primary care, to request an appointment (within a maximum of 72 hours) with the internist, to discuss diagnostic test results (ECG, radiographies, etc.) and to request patient reports, thereby avoiding unnecessary checkups and appointments.
Medical staff involved: one internist until February 2010, and subsequently three.
Infrastructure: the intention was to use already existing personnel (nursing and administrative staff) and facilities; for this, a hospital ward was restructured, being used jointly with the medical and surgical short stay unit (SSU), with the following facilities: a consultation room, day hospital area and conventional inpatient beds.
The initial catchment population of the PCIM CCU, when there was only one internist, was 58,479 people under the care of three health centres (two urban centres, within 10 minutes on foot from the hospital and a rural one 85 km from the hospital). In February 2010, the project was extended to seven health centres, increasing the catchment population to 134,613 and involving three internists.

Results
The data on the activity of the PCIM CCU in its fiveyears of operation are reported below in relation to the various areas of the unit's work.

Remote consultations by mobile/e-mail
A total of 1892 telephone calls were made to the internists, of which only 762 resulted in new patient referrals to the PCIM CCU; the remaining calls were queries that were resolved at the time.

Consultations
A total of 1989 patients were seen. The ratio of followup to first appointments ranged from 0.81 to 1.95; that is, there were fewer than two check-ups for every new patient seen.
The characteristics of patients seen in consultations were as follows [2]: patients with multiple diseases (33%), symptomatic chronic patients (24%), cases in which diagnosis must not be delayed (32%) and non-specific conditions (11%). Of the 762 new patients, we managed to avoid admission in 16% of cases (124 patients) and in 29.66% (228) we avoided patients going to the hospital emergency department, thanks to the support of the Day Hospital and self-management of consultations and beds by the internists leading the PCIM CCU.

Day Hospital
It has four arm chairs for diagnostic and therapeutic procedures. During the study period a total of 676 procedures were carried out, of which the most common were: blood sample collection and parenteral treatments, in particular iron infusion. Other procedures included: para centesis, thoracocentesis, and lumbar punctures.

Hospitalisation
The ward being shared with the SSU, eight beds were assigned to the PCIM CCU. Patients could be admitted either directly from specialist appointments or the Day Hospital, or from the hospital emergency department, provided that they were from the catchment area of the health centres participating in the PCIM CCU programme.
The care indices in 2010 were better that those generated by conventional hospitalisation under the care of the Department of Internal Medicine. In particular, the risk-adjusted average length of stay index was 0.93, that is, lower than the overall value for the Health Service of 1 and that of the Department of Internal Medicine itself, which was 1.01. Further, the impact of the care provided to patients managed by the PCIM CCU is -171, that is, we have saved 171 hospital bed stays, while traditional healthcare under the Department of Internal Medicine used, for the same year, 156 more hospital bed days (impact of +156). Put another way, if we estimate the impact as a function of the standard average length of stay by diagnostic related group (DRG) in the Spanish National Health System, in 2010, the PCIM CCU managed to reduce hospitalisation, saving 171 hospital bed days, while the Department of Internal Medicine oversaw the use of 156 bed days that could have been avoided.

Conclusions
The good outcomes reported are the result of a relatively new approach to care that requires changes in the way of working in both the hospital and primary care. This study demonstrates that the optimisation of hospital resources is feasible through real, effective and personalized coordination between primary care and internal medicine specialists. Despite the fact that healthcare indices generated already indicate benefits of this way of working, further research should be conducted to assess whether it has an impact on the mortality or the readmission rate of patients with multiple chronic diseases.

Resultados
Los datos de la actividad realizada en este tiempo, 5 años, se divide entre los distintos dispositivos con los que cuenta la UCAPI, a saber: