出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Recently, there were implemented several reforms in the Portuguese Health System, in the context of the 2011-2014 hospital reform. One of the main lines of action is the integration of care to optimize resources utilization while improving quality of care. A working group report found almost nonexistent evidence on integration of care in Portugal and recommended the development of case management concept. To pursue the integration of care policy, this recommendation was approved and supported by the Ministry of Health. Description of the policy, objectives and target population To implement the case mangers policy, a multidisciplinary team is following the 4 phases development model for integrated care (Minkman et al.; 2013). The first approach was to define the specific roles of case managers, based on literature review and taking into account the current roles of Portuguese health and social care professionals. The search on pubmed and grey literature retrieved 46 papers/reports. After the definition of the main roles and the target population, case management policy is developed as a pilot experience in a Local Health Unit. The main goal is to improve continuity of care and patient centered care, namely for priority patients with multimorbidity and special health and social needs, improving quality while reducing hospital utilization. The target population, in the first phase, is the frequent users of the emergency room (ER), defined as going 4 or more times to ER in the same year (Pepe et al., 2007). We selected and assessed 3 case studies for case management. The differentiating factor of this policy is the holistic approach, focusing not on the management of one disease, but on the management of the patient with all of his diseases and needs. Key findings : Although the concept of case management is widely spread around the world, we found that literature is scarce concerning the specific roles of case managers and it depends on the context in which it is implemented. The specific roles of case managers in the Portuguese context are the following: - Referral process follow up; - Coordinate care, facilitating collaboration and communication among different professionals (health and social care); - Define a personalized intervention plan; - Empower patients and their families, through self-care and self-management of the diseases; - Suport familiy and carers; - Ensure therapeutic adherence; - Follow up the patient through all levels of care, from the outpatient context to inpatient admission and collaboration in the discharge planning; - Follow up the patient after hospital discharge; - Manage services and resources utilization following clinical guidelines and clinical pathways; - Ensure quality of care, according to best standards, taking patient choices into account; - Report outcomes; Regarding outcomes assessment, we monitor the following indicators: emergency admissions of the target patients, number of inpatient admissions, 30 days readmissions, avoidable admissions, a consultation with the family doctor until 30 days after hospital discharge, time of hospital discharge postponement and patient satisfaction. The expected impact is the improvement of care coordination, a better control of patients with chronic diseases, decrease of avoidable admissions (to the ER and inpatient admissions) and quality of life enhancement. Highlights : The development of the case management policy is in the first steps in Portugal. It needs to be deepened and further tested. Success criteria should be accessed. Conclusion : In Portugal, evidence of integrated care is scarce. Case management is a new policy supported by the Ministry of Health that is being implemented to improve integration of care. The definition of the case manager specific role in the portuguese context might contribute to the enlarged discussion, since there is few evidence about this subject. The pilot experience allows assessing results and success criteria so that it can be transferred to other regions.
关键词：case management ; integrated care ; multimorbidity
