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Effectiveness of a case management model for the comprehensive provision of health services to pluripathological patients

ABSTRACT: Interventions: The recruitment process will follow 2 ways: 1.Based on the characterization, the target population recorded in the database of the insurance health company will be invited to participate until the estimated sample size is completed. 2. During the hospitalization the patients can be detected and invited to participate into the study. In both, the informed consent will be a prior and required procedure. The study will assess the outcomes in the same group of patients before and after intervention. The intervention follows the next steps: 1. Case detection: Identifying if the patient suffers from multiple diseases, if there are readmissions and high demand for health services during hospital stay or according to the reports of the health promoting entity (EPS in Spanish). 2. Case screening: assessing complexity INTERMED scale (European Consultation-Liaison Workgroup for General Hospital Psychiatry and Psychosomatic), medium-high or high). 3. To establish the baseline measurement of indicators to comparate during post-intervention. 4. Comprehensive and multidimensional assessment of the patient: identifying care needs. 5. Assessment of caregiver burden: identifying fatigue and general health status. 6. Personalized care plan: a comprehensive and individual plan is made for each case according to the needs detected. 7. Coordination between providers: contacts and procedures to secure referral to service providers as required by the patient and the family caregiver. 8. Monitoring and evaluation of the personalized plan.;Comprehensive Health Care;Patient Care Management;Long-Term Care;Delivery of Health Care ;Progressive Patient Care;Caregivers Primary outcome(s): 1. Demand for health care services. (Frequency of use of health services for causes related to multi-pathological clinical categories, Measurement tool: Patients Database). Measurement time: At baseline and, 6 months. 2. Admission and re-admission (Frequency of unscheduled admissions and re-admissions related to multi-pathological clinical categories, Measurement tool: Patients Database). Measurement time: At baseline and, 6 months. 3. Pharmaceutical prescription (Medications prescribed to the patient,Measurement tool: drug-dispending database). Measurement time: At baseline and, 6 months. Study Design: Allocation: Non-randomized controlled trial. Masking: Open. Control group: Historical. Assignment: Single group. Purpose: Prevention

DISEASE(S): Multiple Chronic Conditions,Short Breath When Walking On Level Ground At Own Pace Due To Respiratory Distress Which Requires Rest,Dyspnea Assessed With The Medical Research Council (mrc) Scale Or Fev1 <65%, Or Sao2 =90%.- Category D: Inflammatory Bowel Disease. Chronic Liver Disease With Data On Hepatocellular Failure (inr >1.7, Albumin <3.5 G/dl, Bilirubin >2 Mg/dl) Or Portal Hypertension (defined By The Presence Of Clinical, Analytical, Sonographic Or Endoscopic Data).- Category E: Stroke. Neurological Disease With Permanent Motor Deficit That Causes A Limitation In The Basic Activities Of Daily Living (barthel Index Less Than 60). Neurological Disease With Permanent, At Least Moderate, Cognitive Impairment (pfeiffer With 5 Or More Errors)- Category F: Symptomatic Peripheral Arteriopathy. Diabetes Mellitus With Proliferative Retinopathy Or Symptomatic Neuropathy.- Category G: Chronic Anemia Due To Digestive Losses Or Acquired Hemopathy Secondary To Curative Treatment With Hb <10mg/dl In Two Separate Determinations For More Than Three Months. Active Solid Or Hematologic Neoplasm Not Secondary To Treatment W,Multi-pathological Condition. According With Working Group Of The Sociedad Española De Medicina Interna (semi), A Patients Are Defined As Multi-pathological Or Polypathological When They Have Chronic Diseases That Belong To Two Or More Of The Eight Next Categories:-category A: Nyha Heart Failure Class Ii (slight Limitation Of Physical Activity, In Which Ordinary Physical Activity Causes Dyspnea, Angina, Fatigue Or Palpitations). Ischemic Heart Disease.- Category B: Vasculitis And Systemic Autoimmune Diseases. Chronic Kidney Disease Defined By Elevated Creatinine (>1.4 Mg/dl In Men Or >1.3 Mg/dl In Women) Or Proteinuria (albumin/creatinine Ratio >300 Mg/g, Microalbuminuria >3mg/dl In Urine Sample Or Albumin >300 Mg/day In 24-hour Urine, For 3 Months).- Category C: Chronic Respiratory Disease Classified As Mcr Grade 2 (unable To Keep The Pace Of Another Person Of The Same Age

PROVIDER: 2571634 | ecrin-mdr-crc |

REPOSITORIES: ECRIN MDR

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Effectiveness of a case management model for the comprehensive provision of health services to pluripathological patients

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