Table 1
Participating Primary Care practices distribution.
| Primary Care Centre | POPULATION ≥14 years old | Attended | %>75 years old | MEDEA INDEX |
|---|---|---|---|---|
| NORD | 13700 | 84.04% | 9.22% | 1,56 |
| CA N’ORIAC | 17198 | 82.17% | 9.97% | 1,41 |
| CONCORDIA | 12749 | 82.57% | 9.37% | 0,49 |
| Total | 43647 |
Table 2
Demographic and clinical data available in electronic health records.
| IDENTIFICATION, patient ID | ||
|---|---|---|
| Referent Physician | ||
| Referent Nurse | ||
| Clinical Risk Group | See description in text | |
| Risk of admission | See description in text | |
| Adjusted Morbidity Group | See description in text | |
| Age | ||
| Previously identified as “Advanced chronic disease and life limited prognosis” (MACA) | Yes □ | No □ |
| Previously identified as “Complex Chronic Patient” (PCC) | Yes □ | No □ |
Table 3
Chronicity Prevention and Care Programme (PPAC) criteria.
| COMPLEXITY CRITERIA | ANSWER |
|---|---|
| Patient-dependent criteria (PPAC) | |
| Multimorbidity (≥2 chronic diseases) | Yes/No/Don’t know |
| A single severe chronic disease (including advanced frailty states) | Yes/No/Don’t know |
| A chronic progressive disease | Yes/No/Don’t know |
| High probability of undergoing decompensations with many symptoms and poor control | Yes/No/Don’t know |
| Patient with very dynamic evolution, variable, who needs continuous follow-up | Yes/No/Don’t know |
| High utilization of health services (emergency, Primary care appointments) | Yes/No/Don’t know |
| Polypharmacy (≥ 5 medicines) and/or high cost of resources | Yes/No/Don’t know |
| Frail patients with functional loss, probability of acute deterioration (functional or cognitive) or new onset of geriatric syndromes | Yes/No/Don’t know |
| Professional Dependent criteria (PPAC) | |
| Need for multidisciplinary hospital management | Yes/No/Don’t know |
| Need to activate and manage access to different resources (often by preferred routes) | Yes/No/Don’t know |
| Environment of special uncertainty in the decisions and doubts in clinical management | Yes/No/Don’t know |
| Social complexity | |
| Patient with adverse psychosocial situations (PPAC) | Yes/No/Don’t know |
| Patient whose management would benefit from integrated care strategies (PPAC) | Yes/No/Don’t know |
| Patient with relational problems | Yes/No/Don’t know |
| Patient with economic problems | Yes/No/Don’t know |
| Patient with loss of functional autonomy | Yes/No/Don’t know |
| Other criteria | |
| Patient with chronic neurological disease | Yes/No/Don’t know |
| Patient with severe mental disorder | Yes/No/Don’t know |
| Patient with dementia | Yes/No/Don’t know |
| Patient with psychic disability | Yes/No/Don’t know |
| Elderly patient (≥75 years old) | Yes/No/Don’t know |