The care manager as a key role for optimising resources/Las gestoras de casos como elementos claves en la optimización de recursos

CC is associated with patients perceiving a level of consistency and connectedness in their care experience over time. Three inter-related types of CC have been identified [2, 3]: a) relational: the perception of the user with regards to their relationship over time with one or more providers; b) informational: the perception of the user with regards the availability, use and interpretation of the information on previous events to provide care appropriate to their current circumstances, and c) management: the perception of the user that they receive the different services in a coordinated and complementary manner, without duplicity. Each type of CC is characterised by a series of dimensions and attributes and can be analysed in a specific clinical episode or from the general perceptions of users [1–3].


Introduction
Continuity of care (CC) is based on patient and family care as the main element, with a bidirectional relationship between healthcare and social care services; the main aim being to avoid a lack of coordination between levels of care which could be detrimental to users [1].
CC is associated with patients perceiving a level of consistency and connectedness in their care experience over time. Three inter-related types of CC have been identified [2,3]: a) relational: the perception of the user with regards to their relationship over time with one or more providers; b) informational: the perception of the user with regards the availability, use and interpretation of the information on previous events to provide care appropriate to their current circumstances, and c) management: the perception of the user that they receive the different services in a coordinated and complementary manner, without duplicity. Each type of CC is characterised by a series of dimensions and attributes and can be analysed in a specific clinical episode or from the general perceptions of users [1][2][3].
It has been reported that CC is associated with higher levels of user satisfaction [4][5][6][7][8], better perceived quality of life, greater use of preventive services [5][6][7][8][9], higher rates of adherence to treatment [7,8] and decreases in hospital admission rates [5,6,[8][9][10]. On the other hand, rapid technological advances and changes in the organisation of health services, as well as the growth in the prevalence of complex chronic diseases and the number of patients with multiple diseases, mean that patients tend to be seen by a large number of providers in different organisations and services. In turn, this makes it difficult to coordinate their care and, therefore, threatens CC [2,11,12]. For this reason, health systems usually include CC in their quality improvement plans for complex chronic diseases so that it is considered across the system in the ways of working and included in the training programmes of health professionals [13,14].
In relation to this working model, the objectives of our case management service are: To optimise and rationalise the use of services and 1.
of resources to prevent admissions due to clinical worsening of people with chronic diseases, that is, avoiding unnecessary transfers to hospital To decrease visits to the emergency department 2.
by people with complex conditions, as well as their number of admissions and, if admitted, the length of their hospital stay To empower family members by providing them 3.
with the necessary tools to avoid clinical worsening and manage risky situations.

Description of the intervention
This intervention was based on the work carried out by a case management unit composed of nurses. Case Management is the process of systematic and dynamic collaboration to provide and coordinate health services for a given population. That is, it is a participative process to enable access to a range of options and services that cover patient needs, as well as reducing fragmentation of care and duplicity of services, while improving the quality of care and cost-effectiveness in the achievement of clinical targets [15].
Patients included on the list of the case management unit under study had complex conditions and had been referred from Primary Care (through review of patient clinical histories and referrals of health professionals) or Specialised Care (hospital admissions and social care services). A patient was considered to be complex on the basis of meeting 5 of the following 10 criteria, agreed by the case management unit: ≥65 years old 1.
Comorbidity according to the Charlson index 2.
taken continuously Terminal stage of a disease 4.
[17] of ≤55, as an assessment of independence in the basic activities of daily living (BADL) Dementia or cognitive deterioration (Pfeiffer's Short 6. Portable Mental Status Questionnaire [18] score >5) Two or more unplanned hospital admissions due 7.
to clinical worsening in the previous 12 months Three or more visits to a hospital emergency 8. department in the previous 12 months More than 2 falls in the previous 2 months 9.
Living alone or with caregiver who can only pro-10.
vide a limited amount of support, as assessed by a social risk indicator ('TIRS' ≥1) (Annex 1) A descriptive study was carried out comparing a period of one year (from January to December 2010) before and after the management unit was established. For this, data were collected on the basis of the 10 aforementioned criteria, agreed in the case management unit, indicating the level of complexity of the patients.
The geographical area, on the outskirts of the city of Barcelona, is the district of Baix Llobregat Litoral which, including the towns of Gavà and Viladecans among others, can be defined as urban and has a population of 120,000. The different levels of care are offered by the same health service provider. On the other hand, they do have different IT systems, but health professionals can access patient data through shared medical records (SMRs).
The study population was composed of 78 patients with complex chronic conditions. The inclusion criteria were: patients being registered in the unit and having a level 6. An apparent lack of financial resources: this refers to statements by the family and also the impression of professionals (by observation)

YES NO
Score: 'Yes' response to 1 or more item=Social risk.
of complexity ≥5 at baseline. After the overall assessment of the patients, the intervention carried out by the nurses was to agree treatment with the patient, producing a personalised care plan with the collaboration of informal caregivers and of the professionals involved in the patient's care at the various levels of care.
Data were retrieved from the primary care and the shared medical records. They was then analysed using the most suitable statistical tests for each of the variables.

Results
The level of complexity decreased in 55.76% of patients (n=44) (Figure 1).  We also observed a decrease in the number of visits to the emergency department and in the length of hospital stay, both results being statistically significant (Table 1).

Conclusions
The case management model facilitates the three main types of continuity of care: relational, informational and management. The observed reduction in the complexity of the patients indicates that patient health problems were being more effectively monitored by nurses, which enabled worsening in their chronic conditions to be avoided, and in turn a more rational use of health service resources. This indicator is related to activities affecting the three aforementioned types of continuity of care with an associated improvement in patient perceived quality of life and level of satisfaction.
Further, our data demonstrate that the intervention significantly reduced Emergency Department attendances and hospital admissions, while inpatient stays tended to be shorter.

Conclusiones
El modelo de gestión de casos facilita la continuidad asistencial en los tres ámbitos de actuación: relación, información y gestión. La mejora del grado de complejidad de los pacientes indica que el nivel de vigilancia de las enfermeras respecto a los problemas de salud de los pacientes es mayor, evitando así reagudizaciones de sus procesos crónicos, con lo que se racionaliza el consumo de servicios sanitarios. Este indicador se desprende de los tres ámbitos de actuación mencionados anteriormente donde hay una mejora en la percepción de calidad de vida y el grado de satisfacción por parte de los pacientes. Los resultados obtenidos demuestran una disminución en el número de ingresos hospitalarios significativo, de las visitas a urgencias, y en el tiempo de estancia hospitalaria.
La recogida de la información se hizo a través de la explotación de datos de la historia clínica de Atención Primaria e HCC. El análisis de datos se realizó con las pruebas estadísticas más adecuadas para cada tipo de variable.