Impact of a Proactive and Integrated Health Intervention Between Different Assistance Levels Over Some Indicators in the Care of Chronic Complex Patient (CCP)
Overview
- Phase
- N/A
- Intervention
- Not specified
- Conditions
- Preventive Care
- Sponsor
- María José del Olmo Rubio
- Enrollment
- 28
- Locations
- 1
- Primary Endpoint
- Pre-post change in days of Hospital stay from baseline to 16 weeks.
- Status
- Completed
- Last Updated
- 9 years ago
Overview
Brief Summary
The aim of this study is to assess the effectiveness of proactive and integrated healthcare program for chronic complex patients (CCP). This program are based in coordination the primary level of attention with and speciality level. The objective is reducing hospital readmissions and know the benefit in total cost of care in 4 month before and 4 after intervention.
Detailed Description
Quasi-experimental study with single-arm (pre-post study design without control group). The investigators checking pre and post intervention the effectiveness of a healthcare program for CCP. The interventions consist: 1. - Help the nurse in the hospital to carry out the care plans and the continuity care report. 2. - Refer patients to the social workers. 3. - Collaborate with the social worker to refer to centers of media, long stay and reference hospital. 4. - Ensure the follow-up appointments for the CCP. 5. - Make proactive calls to the CCP and/or their caregiver after discharge 6. - Plan the hospital discharge 48 hours in advance, so that the family and the patient can be organized. The investigator analysed if with this program, the CCP reducing hospital readmission and reducing the Hospital expenditure.
Investigators
María José del Olmo Rubio
Principal investigator
Hospital Universitario 12 de Octubre
Eligibility Criteria
Inclusion Criteria
- •Patient ≥ 75 years.
- •Having attended 5 or more emergency visits or having had more than 3 hospital admissions in the last 12 months.
- •Identified with social risk alert.
Exclusion Criteria
- •Participate in other health programs (AHT, diabetes mellitus,...).
- •Terminal patient.
Outcomes
Primary Outcomes
Pre-post change in days of Hospital stay from baseline to 16 weeks.
Time Frame: Baseline and 16 weeks.
The same group of patients are analyzed the days of hospital stay at the end of 16 weeks of follow-up pre intervention (baseline) and 16 week after the intervention.
Secondary Outcomes
- Number of primary care visits for CCP change from baseline to 16 weeks.(Baseline and 16 weeks.)
- Number of urgency visits for CCP change from baseline to 16 weeks.(Baseline and 16 weeks.)
- Number of hospital readmissions visits for CCP change from baseline to 16 weeks.(Baseline and 16 weeks.)