Abstract
Background: Spain, as a social and democratic state, is committed to ensuring equality of opportunities for all its citizens, which includes fundamental rights in the healthcare and social spheres. The General Health Law of 1986 established a National Health System (NHS) that provides universal healthcare, while the System for Autonomy and Care for Dependency promotes access to social benefits for dependent populations.
In the Balearic Islands, this framework is complemented by regional legislation aimed to ensure the quality of life and autonomy for individuals through diverse socio-health services. However, the lack of coordination among these services is particularly evident in the case of the institutionalized population, due to both the disruption of continuity by their primary care professionals—who are central to our NHS—and the multiplicity of actors involved, including private companies, nursing homes professionals, and representatives from health and social services’ public administrations.
Approach: The creation of the integrated care promotion team for nursing homes (EPAIB-RES) in 2023 materialized as a response to these challenges. This multidisciplinary team in Mallorca comprises five nurses, two physicians, and one pharmacist, with the goal of improving healthcare for 3,580 patients living in 41 nursing homes, focusing particularly on those with complex and advanced chronic conditions. The EPAIB-RES aims to foster effective communication between different levels of care, including primary care, hospitals, and health services, thereby facilitating a comprehensive and patient-centred care model.
Results: Since its inception, the EPAIB-RES has implemented numerous interventions at both the residential and individual levels. A total of 272 systemic interventions have been conducted, which include the team presentations to the 41 nursing homes in Mallorca and their corresponding 24 Primary Care facilities, management of outbreaks in collaboration with Public Health, mediation between the nursing homes and various healthcare resources, among others. These actions have established a network of communication and support between healthcare professionals and nursing homes, establishing the EPAIB-RES as a link between them.
At the individual level, the team has conducted 9,006 interventions, 1,846 of which are comprehensive geriatric assessments. These assessments include the identification of chronic patients with complex needs and those with palliative needs, the identification of geriatric syndromes, review of polypharmacy, and close follow-up of complex cases. So far, approximately 25% of users living in nursing homes have been thoroughly assessed, demonstrating the team's ability to respond to the needs of this population.
Implicactions: Demographic trends predict a significant increase in the fragile and vulnerable population with greater healthcare and social needs in the coming years. The fragmentation of healthcare and social services generates inefficiencies and adversely affects users, making it imperative to advance the creation of a common socio-healthcare space.
Coordinated projects, such as the development of an interoperable medical record system, case management initiatives, the establishment of consensual protocols, and the existence of teams like EPAIB-RES, serve as successful examples that can provide a solid ground for a future healthcare patient-centred model.