Table 1.
Definition of the lines of action for complex chronic patients
| Line 1: Identification of the target population |
| Line 2: Accessibility and coordination of care |
| Establish a coordinated care pathway for use on discharge to ensure that patient care is well coordinated in primary care |
| Define and implement emergency care protocol for complex chronic patients |
| Line 3: Proactive actions for patient monitoring |
| Line 4: Organisational culture |
| Make available a guide to social services that defines the procedures to be followed |
| Create forums to make all healthcare professionals involved aware of the different strategies |
Table 2.
Characteristics of the predicted target population: use of services*
| Predicted cases | Rest of the population | Ratio (A/B) | |
|---|---|---|---|
| Acute admissions (episodes) | 18.3 | 3.2 | 5.8 |
| Total stay in acute hospital (days) | 153.0 | 17.2 | 8.9 |
| Mean length of stay/admission in hospital (days) | 8.4 | 5.4 | 1.5 |
| Long-term care/Nursing home admissions (episodes) | 6.0 | 0.2 | 24.1 |
| Hospital emergency department attendances | 6.7 | 2.8 | 2.4 |
| Outpatient appointments | 473.8 | 103.6 | 4.6 |
| Primary care emergency service attendances | 13.2 | 7.2 | 1.9 |
| Visits to primary care centres | 1184.3 | 356.7 | 3.3 |
[i] *Six-month period: data expressed as number per 100 people.
Table 3.
Outcomes of the pilot project*
| Assessed/ | Valid cases | % of sample |
|---|---|---|
| Prescriptions | 87 | 90.8 |
| Adherence to medication | 86 | 80.2 |
| Compliance with appointments | 84 | 77.4 |
| Proper use of inhalers | 45 | 47.6 |
| Dietary control | 82 | 53.7 |
| Independence (Barthel scale) | 77 | 71.4 |
| Social risk (“TIRS” Scale) [7] | 33 | 12.1 |
[i] *Total n=94 cases.