Effectiveness of a Multidisciplinary Care Management Program for High-risk Patients Who Are Admitted at Hospital Because of Heart Failure (PROMIC)

INTRODUCTION In light of the increased prevalence of chronic diseases and comorbidities as a result of the increased life expectancy of the population, the need to develop care models that adequately respond to the healthcare and sociodemographic needs of the populatión in the actual context in which they are applied has been proposed. Patients with chronic and/or multiple diseases present the greatest health care needs and tend to experience the imbalances in the system with the greatest intensity. Investigators have concentrated the research on patients admitted because of HF due to the high prevalence and complexity of this disease and the fact that such patients present multiple chronic conditions. These patients are normally elderly and present high degrees of comorbidity and poly-medication, poor treatment adherence and difficulties in selfcare. The majority of patients admitted with HF are in level 3 of the Kaiser pyramid together with other patients with complex health care needs.

There is some evidence that a higher degree of multidisciplinarity results in better team coordinatión and training and more effective care for complex high-risk patients, of which HF patients are a good example.

PROMIC is an organisational care management innovation that provides a comprehensive and integrated approach to patients with a high degree of complexity, in this case, patients admitted with HF.

It promotes the integratión of care in different healthcare settings with the change of the nurses role and self-care training in patients. As such, PROMIC helps to ensure the continuity of patients care in their own environment.

The aim of the innovative care model that PROMIC is intended to provide in high-risk HF patients is to improve health outcomes and to modify the current care model for chronic diseases, thereby serving as the foundation for future interventions targetting other chronic patients with multiple comorbidities and complex health care needs. Indeed, precisely due to the presence of comorbidities in this type of patient, investigators consider coordination with consultants from other specialities to be essential. As HF patients present marked comorbidity, investigators expect that the experience acquired during this project will help them to design interventions that can be broadened to cover all complex chronic patients likely to benefit from a care management programs.