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Intensive multidisciplinary care programme for frail patients

I Urreta, P Aranegi, J Artetxe, X Zubeldia, I Huerta, J.I. Emparanza

Abstract


Rationale and Objectives: Patients with chronic diseases re-admitted for acute events are associated with a high use of hospital resources and represent a challenge for healthcare systems. In such cases, follow-up interventions at discharge can be effective. The widespread adoption of follow-up procedures not involving telemonitoring may greatly decrease re-admissions rates without the costs associated with telemedicine. To assess the impact of a structured follow-up programme on patient-perceived healthcare quality, treatment adherence, re-admissions and Emergency Department attendances.

Methods: This was a before and after study of 242 patients at risk of re-admission for chronic obstructive pulmonary disease (COPD) or heart failure (HF), recruited between 1st July 2009 and 30th June 2010 at Donostia Tertiary University Hospital (Gipuzkoa, Spain). The follow-up ended on 30th December 2010. The intervention involved identifying independent re-admitted patients, providing personalised information and a direct number to call in the event of clinical worsening, assigning specialists and liaison nurses, structured follow-up by telephone and appointments and contact with general practitioners. Patient perceived quality of care estimated was analyzed using a focus group technique. To assess the number of re-admissions and the Emergency Department attendances we estimated the relative risk reduction as a percentage and corresponding 95% confidence intervals.

Results: In terms of perceived quality of care, the most valued elements were related to having an assigned doctor/nurse and easy access in the event of worsening. Overall, 97.9% of patients reported full adherence to treatment (95% CI: 95.4-98.83).

Hospital bed days and Emergency Department attendances decreased by 60.7% (95% CI: 58.7-62.7) and 77% (95% CI: 73.2-80.3), respectively.

Conclusions: The intensive multidisciplinary care programme can reduce Emergency Department attendances and improve perceived quality of care in patients with HF and COPD.

Keywords


Chronic diseases, chronic obstructive pulmonary disease, emergency department attendances, frail patients, heart failure, multidisciplinary care, multidisciplinary team, older patients, person-centered care, preventable admissions, re-admissions, treatmen

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DOI: http://dx.doi.org/10.5750/ejpch.v2i3.724

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