Abstract
The creation of Integrated Assistance Pathways (PAI) for people with Heart Failure (PAI-IC) and Multimorbidity (PAI-MM) was carried out in co-production among hospital professionals, primary health care (PHC), and stakeholders. It is estimated that by 2030, the current incidence of chronic diseases will double among people over 65 years old. The pathologies Heart Failure, Diabetes, and Chronic Obstructive Pulmonary Disease were selected due to their high prevalence in the population, morbidity and mortality rates, and the impact they represent on human resources (HR), which are finite and must be optimized. The implementation of the pathways involved a restructuring of care delivery without increasing HR. The computerization of the PAI in interoperability with S.Clinic allows for clinical decision support, automation for follow-up, and alert generation (through the responses of users/caregivers to the decompensation signs questionnaire). The creation of 6 Connection Teams (CT) (5 PHC and 1 hospital) consisting of doctors and nurses was essential. The CT operates daily, ensuring the coordination of care, providing close support between professionals (inside and outside the institution), managing alerts and phone contacts, evaluating users in person whenever justified, guiding and empowering patients/caregivers for self-monitoring, ensuring periodic clinical assessment, conducting in-service training, and meeting monthly for sharing/discussion/reflection. The computerization of the PAI has facilitated follow-up in different contexts (PHC, Residential Structures for the Elderly, hospital consultations, Emergency Service (ES), hospitalizations, and Day Hospital), allowing the CT to always have the patient on their “Radar”: the right care, at the right time, by the most appropriate team. Results obtained - 3437 eligible users, 1171 with activated journeys (34%) - 5195 communications with a 63% response rate: 83% by the patient/caregiver - 40% generated alerts - 39% moderate; 61% critical - 2% of alerts led to clinical evaluation - Reduction of ES episodes: 48% less in PAI-IC and 44% less in PAI-MM with statistical significance (P<0.001). The PAIs reduce care fragmentation and constitute a bridge between different contexts, reinforcing trust among various types, serving as a contact platform for patients/caregivers and professionals. The way the CT operates is crucial in reorganizing health care, placing the patient at the center of the system. The work of the CT reflects an improvement in empowerment, recognition, and monitoring of decompensation signs, increasing the safety of patients/caregivers and reducing the likelihood of trips to the ES.
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