Chronic patients in Barcelona: Primary School-Vall d’Hebron join forces

The Vall d’Hebron University Hospital and the Barcelona Ciutat Primary Care Territorial Management (Apbcn) of the Catalan Health Institute (ICS) have launched a multilevel program in the Àrea Integral de Salut (AIS) Barcelona Nord, the reference area of ​​the Hospital, to improve healthcare and the quality of life of patients with complex chronic pathology who present multiple frequent visits to the Hospital’s Urgències Service -some patients who have been discharged for the second time in six months.

The Minister of Health, Manel Balcells i Díaz, has confirmed that this care program “is an example of the model that we are promoting from the Department of Health and that we would like it to be, not only a successful experience, but also a model to follow in the whole territory“. Balcells has explained that its suitability lies in the fact that it is a specific attention to this profile of complex chronic patients, preventive and with spaces oriented to this type of typology of patients, which makes it “one of the basic instruments for the decongestion not only in hospital emergencies“, but above all to improve the care and quality of life of these patients, who can be served more directlyto avoid these decompensations”.

The new program has started to be applied in patients with chronic obstructive pulmonary disease and heart failure, two of the pathologies with the highest prevalence among the elderly. The number of people over the age of 80 will triple between 2020 and 2050according to the World Health Organization (WHO), and will exceed 426 million people worldwide.

How is it coordinated?

Vall d’Hebron Hospital is proactive in detecting these chronic patients complexes of the AIS Barcelona Nord, which, if their medical situation worsens, resort to the Servei d’Urgències, to refer them to the level of health care that best suits their needs: Primary Care, intermediate outpatient care or specialized hospital care. “This program is a model of how health agents who work in the same area, the AIS Barceloan Nord in our case, join efforts for the benefit of complex chronic patients: Vall d’Hebron’s commitment to coordination with the territory goes through carry out projects that consolidate the continuity of care to Primary Care and with intermediate outpatient care devices”, exposes Albert Salazar, manager of the Vall d’Hebron Hospital.

“The data from most studies suggest that optimal coordination between Primary Care and hospital care in patients with these pathologies reduce the rate of readmissions potentially preventable and reduces the risk of adverse clinical events,” says Ricard Riel, manager of the Atenció Primària Barcelona Ciutat. “Thanks to the new program we offer each patient the therapeutic plan that best suits her needs to improve her quality of life and care for your chronic health problems with a holistic vision, which also takes into account their social and family situation”, explains Anthony San JoseHead of the Internal Medicine and Geriatrics Section of the Vall d’Hebron University Hospital

In accordance with the new program, the computer system of the Vall d’Hebron University Hospital automatically prepares a daily list of complex chronic patients discharged for the second time in six months in the Hospital’s Urgències Service, whether or not they have required admission hospitable. This list is reviewed by the Vall d’Hebron nurse case manager, Martha Losadawhich selects these cases in which the second episode of emergency discharge was due to decompensation of heart failure or exacerbation of chronic obstructive pulmonary disease, and evaluates them individually.

After reaching an agreement on the case with a physician from the Vall d’Hebron Internal Medicine – Geriatrics Section, the managing nurse refers the patient to the health resource most appropriate to their clinical condition: their Primary Care Center (CAP), in the case that requires follow-up by reference health professionals; the Equip de Suport Integral a la Complexitat (ESIC) Casernes – Vall d’Hebron or the Hospital de Dia Mèdic Sant Rafael, if you require intermediate outpatient care, or the Vall d’Hebron Pulmonology and Cardiology services, if you need specialized hospital care .

“It is about offering each complex chronic patient the most personalized care possible, keeping the disease under control and ensuring that health care is carried out in their closest environment, since each hospital admission can imply a deterioration in the state of health when treated. of elderly patients”, sums up Losada. Through the programme, if the patient has been discharged from the Vall d’Hebron Urgències Service without hospitalization, between 48 hours and one week after discharge, they receive a phone call from the managing nurse to find out your situation first hand. In the event that the patient has required hospital admission to the acute or intermediate unit, they will be subject to health monitoring, either in person or online.