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Evolution of a multipronged and multi-intevention strategy for patients with high comorbidity

Authors:

Uxue Errasti ,

Hospital Universitario Donostia, ES
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Naiara Pérez-Fernández,

Hospital Universitario Donostia, ES
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Maitane Elola,

Hospital Universitario Donostia, ES
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Ana Fuertes,

Hospital Universitario Donostia, ES
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Marta Vaquero,

Hospital Universitario Donostia, ES
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Ander Berroeta,

Hospital Universitario Donostia, ES
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Ander Alberdi,

Hospital Universitario Donostia, ES
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Beñat Zubeltzu,

Hospital Universitario Donostia, ES
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Asier Mitxelena,

Hospital Universitario Donostia, ES
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José Javier Zubeldia,

Hospital Universitario Donostia, ES
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Pedro Aranegui,

Hospital Universitario Donostia, ES
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José María Arteche

Hospital Universitario Donostia, ES
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Abstract

Introduction: In H.U.Donostia (Gipuzkoa) we identified multi-pathological patients with repeated admissions due to the same process. We wondered how to avoid it and design the first studies.

Description of practice change implemented: Evolution of an integration strategy based on person-centered care incorporating liaison nurse, primary and hospital care and hospital at home service (HaH). Impact of new technologies.

Aim:

Improving patients’ quality of live.

Training patients and healthcare providers.

Optimizing the use of healthcare resources.

Establishment of objectives and care directives.

Target population:

- Multi-pathological patients with high readmission rates due to HF and/or COPD.

- Home-dependent patients.

- Nursing home residents.

Timeline:

2007-2008: before-after preliminary study with a multipronged strategy (EMAI) on HF with high readmission rates.

2008-2009: RCT: EMAI vs EMAI + telemedicine.

2009-2010: before-after study with a multipronged strategy (PAMI) targeting patients with high readmission rates.

2010-2011: cluster RCT: PAMI in nursing homes.

2014-2015: RCT: PAMI vs PAMI+web.

2017: RCT: PAMI vs PAMI+osarean.

2017: cluster RCT in home-dependent patients: PAMI vs PAMI+web/APP.

Highlights:

- Preliminary study with multi-intervention EMAI (assignment of a liaison nurse and a hospital-based specialist, structured telephone support, communication with the GP and appointment with the hospital-based specialist):  80% reduction in the number of bed days and in the attendances to the Emergency Department (ED) compared to the previous year.

- PAMI: extension of the previous study with implementation of the multidisciplinary care programme with direct telephone line for maximum accessibility. 60.7% reduction in the number of bed days and 77% in the attendances to the ED compared to the previous year. High adherence to treatment and patient perceived good quality of care.

- With reduction in-patient bed days, increased consultations. Adding telemedicine to PAMI reduced the use of health resources, without impact on the quality of life, but not being cost-effective.

- Adapting PAMI to patients living in nursing homes: reduction in ED attendances and an exchange of inpatients bed days for days cared by HaH without differences in mortality.

- Implementing PAMI with a web-based self-care programme during one year:  no differences in terms of mortality, visits to the ED, hospital admissions or quality of live.

- The liaison nurse call was replaced by a call-center (Osarean) compared to classical PAMI: a decrease in visits to the ED (4%) and days of admission (3%) and an increase in stays in HaH and hospital visits.

- Implementing PAMI with a self-care programme (web or APP) in home-dependent patients: pending results.

Sustainability: Reorganizing healthcare system would allow optimizing actual resources

Transferability: The technology and protocols are available to all in the Basque Country.

Conclusions: Our multipronged strategy demonstrated its efficacy to manage better patients with high rates of readmissions or those with dependency (at home and nursing homes).

Discussion: A unified clinical history accessible to all the agents involved and improving the communication channels would make the strategy more efficient.

Lessons learned: Training both patients and professionals and accessibility to the health system are the main keys in the future to manage multi-pathological patients.   

How to Cite: Errasti U, Pérez-Fernández N, Elola M, Fuertes A, Vaquero M, Berroeta A, et al.. Evolution of a multipronged and multi-intevention strategy for patients with high comorbidity. International Journal of Integrated Care. 2019;19(4):43. DOI: http://doi.org/10.5334/ijic.s3043
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Published on 08 Jul 2019.

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