Abstract
In the management of chronic diseases, the coordination between levels of care is essential to achieve individual goals and optimize healthcare resources.
At the local level, in regions where access to care is limited, a closer relationship between the patient and the health care professionals is essential, to achieve greater health gains. For this reason, the Local Health Unit of Alentejo Litoral (ULSLA), have implemented a Case Management (CM) program
We present a case study that reflects the importance of Coordination of Care in the management of chronic diseases. That’s a 39-year-old Indian man, immigrant in Portugal, self-employed and working in agriculture. He had a personal history of Heart Failure with reduced Ejection Fraction (HFrEF) of 15%, alcohol consumption (20g per day) and no compliance with therapy. He was a frequent user of the ULSLA Emergency Department (ED) – 1 time every 15 days, with more than 2 admissions for HF decompensation in a six months’ period. In June 2020 he was admitted again at the ULSLA hospital, with HF decompensation symptoms, due to non-compliance to therapeutics. During admission, he developed several complications and was placed an ICD for primary prevention, prolonging his hospital admission for 52 days.
He restarted prognostic-modifying therapy with a good clinical evolution. We organized the transition of care with the multidisciplinary CM local team, with an individual care plan.
It was identified that the patient had social needs that were not being addressed and that motivated his multiple returns to the ED, namely the language barrier and the issue of the price of medicines, but he also did not understand his disease or performed adequate rehabilitation. Through the planning and coordination of the professionals of the CM team, it was performed 1 home visit, 43 telephone contacts, 32 consults by the primary care physician and CM nurse, 2 social interventions and the support for transportation for hospital HF appointments. The community services helped him with medicines and the patient’s friends with emotional support, the language barrier and compliance to therapy, giving arise to a holistic approach
He maintains therapeutic compliance, ethanol and smoking avoidance, with adequate knowledge and control of his chronic disease, with an improvement of the rEF (57%). In the last year, he had no recurrences to the ED. So he decided to visit his family in Denmark. When abroad, he had an ED admition, regarding an arrhythmia episode. Because he was so well integrated in the CM program, he managed to established contact between the Portuguese CM team and the Denmark doctors and nurses, improving treatment and an early discharge. He then returned to Portugal.
The coordination between hospital and primary care with a multidisciplinary CM team and the integration of community and social resources in a patient centered perspective are crucial for the management of patients with chronic diseases.