Abstract
Coordinated roles among healthcare providers across diverse settings are vital for seamless care transitions and addressing the burdensome challenges posed by chronic diseases.
Cardiovascular diseases, notably heart failure, pose a significant threat to healthcare sustainability globally, with a prevalence of 64 million people and a five-year mortality rate of 50-75%, making it a top priority in addressing societal and economic impacts.
About our context, ULSLA is a healthcare network, within the Portuguese National Healthcare System, that covers a 5310km2 mixed urban-rural area. It comprises one hospital and five primary care health units, serving a population of over 105 000 patients, including 26.4% aged over 65, 12% migrants, and 28.6% with very low literacy.
Our goal is to enhance heart failure care by focusing on two primary objectives: improving care integration and coordination through a multidisciplinary, automated digital care pathway, and strengthening healthcare professionals' ability to monitor, manage, and track these patients. Additionally, we strive to foster patient engagement and autonomy.
The project began with a workforce of medical doctors, nurses, patients and caregivers from ULSLA primary and secondary care that started mapping out the disease’s clinical pathway across different care settings. UpHill, a medical software company, then customized a digital clinical pathway software specifically for this context and validated it against existing workflows. This solution goes beyond offering personalized clinical decision support; it also integrates real-time clinical data from ULSLA through interoperability and engages patients through a virtual assistant equipped with an alarm system, task automation and process indicators.
A cohort of 552 patients, with an average age of 77 years, were gradually enrolled in their personalized digital clinical pathway. Collaboration among 28 healthcare professionals across six care liaison teams yielded substantial efficiencies, saving a collective workload of at least 85 hours.
Notably, within follow-up automations, a total of 1,309 communications were dispatched, achieving a commendable 72% response rate. Of these communications, 48% prompted a clinical alert, 95% of these alerts were resolved before the anticipated 48-hour timeframe. Remarkably, 92% of the situations that generated an alert were successfully addressed by nurses in a single telephone call, obviating the need for additional medical appointments or Emergency Room admissions.
Furthermore, 20% of the total patient cohort—those fully asymptomatic—received automatic pre-validated instructions, eliminating the necessity for direct human intervention in the follow-up process. This not only streamlined operations but also saved valuable time for healthcare professionals.
The integration of a personalized digital pathway in heart failure care significantly reduced professionals' workload, with good patient engagement and resolution rates for clinical alerts.
Seamless coordination among healthcare providers across diverse settings is imperative for effective chronic condition management, while the transformative potential of digital pathways empowers healthcare professionals and maximizes resource efficiency.
We aim to continue improving the digital pathway using real-world feedback, boosting patient engagement and self-management support, speeding up responses, and optimizing healthcare workflows. Prioritizing patient needs, we tailor the pathway while tracking its long-term impact on outcomes, costs, and system efficiency.