Abstract
Introduction:
A Complex Chronic Disease is a condition involving multiple morbidities that requires the attention of multiple health care providers and, therefore, consume multiple human and material resources.
The Andalusian Public Health System is responsible for the provision of healthcare and public health services to the Andalusian population (8.5 million inhabitants), where around 250000 complex chronic patients (CCPs) have been identified (2018). Since 2016, Personalized Action Plans (PAPs) were introduced as key-elements to provide the needed holistic care. PAPs are written plans designed by multidisciplinary teams (family physicians, nurses, internists, case manager nurses, pharmacists, social workers, among others), and agreed with each patient or family/caregiver.
PAPs are based on a comprehensive assessment of key aspects of patient status (including targeting symptoms, functional ability, quality of life, among others) and their preferences (i.e desired patient out-comes). PAPs incorporate information from different healthcare providers and levels, focusing on patient outcomes rather than disease-specific outcomes.
Within the participation in the EU Joint Action Chrodis-Plus (“Implementing good practices for chronic diseases”, GA761307), a quality assessment of delivered PAPs will be carried out. The Andalusian pilot within the framework of Chrodis-Plus will assess the PAP implementation outcomes.
Method:
The aim of the study is to performe a quality assessment (QA) of the PAPs delivered from December 2018 to February 2019 within the context of Chrodis-Plus. 2700 patients with PAPs have been included in the Andalusian pilot. A random sample of 350 anonymised PAPs have been selected for its QA, to be carried out in late 2019.
Main criteria for the PAPs assessment are:
• All the fields are filled up.
• Fields are filled according to the patient comprehensive assessment and in a friendly-language.
An initial 25 PAPs were peer-reviewed and deeply analysed by an expert panel to define specific scales to be applied in the study.
Results, Conclusions and Lessons learned will be presented during the conference.
It is expected that most PAPs are drafted in agreement to the patient comprehensive assessment, but with a high proportion of technical language and acronyms.
Discussions:
QA is an issue of utmost interest for all healthcare systems allowing improvement of healthcare services performance as well as identifying opportunities and best practices.
There are two key documents for PAPs drafting (the “Integrated Care Process ‘Healthcare for Multimorbidity Patients’” and “Individualized care plans for patients with multimorbidity or with complex health needs. Recommendations for its drawing up”), aiming to ensure the standardization and quality of performed PAPs. In addition, training to professionals involved in the management and treatment of CCPs are provided on a regular basis.
However, to the date, no QA has been carried out to monitor the PAPs drafted within the framework of routine clinical practice.
Limitations:
Peer-review process was applied to initial 25 PAPs, but not to the total sample, which was reviewed by a trained researcher. Additional issues were considered by an expert panel.
Suggestions for future research:
Support CCPs consensus groups in further studies to verify the findings of this one.