出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction: Baix Camp County has a population of reference in 2015 of 188640 people with a 18.57% of over aging (population over 84 years divided by the population of 64 years). Eleven basic primary care settings serve this population with a unique reference for specialized care (SC) which is the University Hospital Sant Joan de Reus. There are two PC providers, the Institut Catala of health and Grup Sagessa, also the specialized care provider. There is a system fragmentation regarding the chronic patient care with a lack of continuity between the two areas (SC and PC) which causes an increased risk in patients’ transitions. This leads to a lack of comprehensive view of the patient with multiple chronic conditions, from a health and social perspective, with a poor management of its complex needs. It increases the number of readmissions and avoidable hospitalizations. There is a support team specialized in geriatrics care for these group of complex chronic patients but is underused by PC without an established system for the assessment and follow up. Short description of practice change implemented, aims, target population and key stakeholders involved We propose a new model of chronic care for older persons with multiple chronic conditions and complex needs. It consists on a program based on a horizontal integration across care settings, primary care (PC) and specialized care (AE). It started in March 2015, coinciding with the beginning of a case manager for chronic patients (GCP) at home in the town of Riudoms. We agreed in the following activation criteria for specialized geriatrics support team (GT): 1. Reactive: acute decompensations, use of an emergency resource (PC or EC) , review of drug prescriptions and end-of-life situation. 2. Proactive: frequent attendance of emergency resources (> two visits in the last six months), polypharmacy (consumption > 7 drugs), support for continued care of PC and specific diseases as dementia, COPD and heart failure. Main objectives: - Increase the identification of complex chronic patients in the medical record shared for both levels(HC3) - Reduce hospital readmissions
关键词：integrated care ; primary care ; geriatrics ; chronic patients
