Integrated care program for complex chronic patients

Introduction : MutuaTerrassa (MT) provides comprehensive primary care and specialty services as well as mental and socio-healthcare through an integrated service model. MT designed a new model of integrated care for chronic conditions focused on different segments of the population in 2012, with the ultimate goal of achieving a model of care that is more decisive and satisfactory both in prevention and in treatment of chronic patients. Goals : The aim of this project was to develop a new organizational and functional structure called Functional Unit of Chronic Patient (FUCP) to meet the needs of a subgroup of chronic patients with great complexity and fragility, or the so-called Chronic Complex Patient (CCP). Description : The Functional Unit of Chronic Patient made up of a multidisciplinary group of professionals and levels of care, working together on a selected group of patients who are identified based on clinical and social criteria, following defined protocols, making care circuits consensus and sharing information. To develop this unit, some actions were deployed at multiple levels. Among the most important are those relating to designing management and care coordination, selecting and identifying patients in the new unit, creating the structure of the FUCP, defining categories and profiles as well as its functions, reorganizing the various health care facilities in the network to prioritize their co-operation, redesigning working relationship tools between different devices, creating a functional plan, and defining monitoring indicators such as activity, process and outcome. Results : The project results can be summarized in two main areas; firstly, assessing the degree of implementation of the program and, secondly, the results of care measured by indicators of activity (annual healthcare activity conducted by the FUCP), care process (PCC identification and set up of an individual therapeutic plan (PIIC)) and outcome (number of emergency admissions and emergency room visits of patients identified). The overall objective of the project was the implementation of the FCCU in 2012, when the first level FUCP, the second level FUCP devices for outpatients and day hospital, and the intermediate care unit were launched. Likewise, the basic circuits between the three levels of care and support network were defined, and the most important relationship instruments developed. Regarding healthcare monitoring, different areas have been analyzed. The care process has been measured by the number of CCP identified and ITP designed. In December 2015, there were 4.516 CCP registered (1.75% of population) and 76.15% of them had an ITP (1.33% of population). Preliminary results of the global program were evaluated in late 2013, demonstrating a reduction of 32% of emergency hospital admissions and 29% of emergency room visits made by identified patients. Since the creation of a respiratory FUCP until December 2015, 176 patients were identified as CCP and evaluated, 60 of them were included in the unit as new patients. The 92% of patients reduced the number of admissions during the first year monitoring (57% of them without any more hospital admission and 35% with hospital admissions reduction) and there were also a reduction of 67% in the overall number of hospital admissions made by these 60 patients. Likewise, the results of 18 months of mental health FUCP working showed that 45 patients were included, 18 of whom had had 31 emergency hospital admissions over the last 12 months; there were only 4 emergency hospital admissions during follow-up and 14 patients were discharged of the program mainly due to clinical improvement. Discussion and conclusions : The Functional Unit of Chronic Patient of MT is consolidated in our area of reference. Its activity is high and increasing, both in terms of new devices as number of patients registered and monitored in the unit. We can also say that preliminary clinical results have been very good, reaching out the objectives outlined, basically reducing emergency hospital admissions and emergency visits. We are currently following the evaluation process of the different subgroups of patients included in the program and developing new circuits, protocols, devices, and support sub-projects that will allow us to move forward in the continuous improvement of the FUCP of MT. Likewise, we are also working in new indicators to asses quality of care and patient satisfaction.