Abstract
Introducción: In aging populations, multimorbidity is very common. Patients with multimorbidity who have complex health and social needs, are at risk of being admitted to the hospital or residential care home and require a wide range of interventions. So, new integrated care models are needed. It should be more patient-centered and it should have primary care as the cornerstone of care. Empowered patients and carers; information and communication technology platforms and care pathways will ease and improve coordination. The CMPCP is the selected tool to face this tackle since 2016 in BHS but Covid19 might have affected the care path effectiveness.
Objectives: To know the impact of the pandemic on the CMPCP.
To propose by all the organizations different actions that will overcome and facilitate its implementation corporately.
Incorporate a route map for rescale up in the organization.
Material and method: A working group with professionals from Primary and Hospital settings, Nursing, Research Agency and TICs.
A questionnaire ( 20 questions) following the guide for the design and implementation of care pathways in the BHS.
Two-hour zoom meeting with each integrated Health organization following the questionnaire.
A document with the new road map to be deployed in 2022.
Results: Regarding Leadership and the Agents involved it is important the referral internist and the joint work with General Practitioner (GP) is emphasized (93%), but this role is weighed down by the effect of the pandemic. The social workers and their coordination with GPs is low,(50%). Tools used in the management of the CMPCP, as the individualized care plan, stratification, assessment tools, health advice center, are used in practically all organizations, although the ""pandemic effect"" has significantly affected. It is low used-level of tools related to patient empowerment (67%).Other tools as video calls, are yet quite low (20%).In the ""communication channels"" the most used ones were telephone and interconsultations, and the shared clinical sessions. Medication adherence and conciliation, register a very low use of 47%.The organizations state that this ""patient vision"" should be reinforced in the pathway through surveys, focus groups, etc, but not necessarily engaging them in the whole process
Conclusions: This revisiting process base on questionnaires and discussion meetings gave us relevant information to guide our next steps for the new normality. A new route map with a number of initiatives has been develop which will be deployed through 2022.
Implications for applicability: The pandemic hit the health system dramaticaly , particularly to the multimorbid population. needless to say that fragmentation between levels could have risen. in this scenario some actions were absolute necessary so we needed to know how big affectation was in order to get on with the proper actions