出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : In H.U.Donostia (Gipuzkoa) we identified multi-pathological patients with repeated admissions due to the same process. We wondered how to avoid it and design the first studies. Description of practice change implemented : Evolution of an integration strategy based on person-centered care incorporating liaison nurse, primary and hospital care and hospital at home service (HaH). Impact of new technologies. Aim : Improving patients’ quality of live. Training patients and healthcare providers. Optimizing the use of healthcare resources. Establishment of objectives and care directives. Target population : - Multi-pathological patients with high readmission rates due to HF and/or COPD. - Home-dependent patients. - Nursing home residents. Timeline : 2007-2008: before-after preliminary study with a multipronged strategy (EMAI) on HF with high readmission rates. 2008-2009: RCT: EMAI vs EMAI + telemedicine. 2009-2010: before-after study with a multipronged strategy (PAMI) targeting patients with high readmission rates. 2010-2011: cluster RCT: PAMI in nursing homes. 2014-2015: RCT: PAMI vs PAMI+web. 2017: RCT: PAMI vs PAMI+osarean. 2017: cluster RCT in home-dependent patients: PAMI vs PAMI+web/APP. Highlights : - Preliminary study with multi-intervention EMAI (assignment of a liaison nurse and a hospital-based specialist, structured telephone support, communication with the GP and appointment with the hospital-based specialist): 80% reduction in the number of bed days and in the attendances to the Emergency Department (ED) compared to the previous year. - PAMI: extension of the previous study with implementation of the multidisciplinary care programme with direct telephone line for maximum accessibility. 60.7% reduction in the number of bed days and 77% in the attendances to the ED compared to the previous year. High adherence to treatment and patient perceived good quality of care. - With reduction in-patient bed days, increased consultations. Adding telemedicine to PAMI reduced the use of health resources, without impact on the quality of life, but not being cost-effective. - Adapting PAMI to patients living in nursing homes: reduction in ED attendances and an exchange of inpatients bed days for days cared by HaH without differences in mortality. - Implementing PAMI with a web-based self-care programme during one year: no differences in terms of mortality, visits to the ED, hospital admissions or quality of live. - The liaison nurse call was replaced by a call-center (Osarean) compared to classical PAMI: a decrease in visits to the ED (4%) and days of admission (3%) and an increase in stays in HaH and hospital visits. - Implementing PAMI with a self-care programme (web or APP) in home-dependent patients: pending results. Sustainability : Reorganizing healthcare system would allow optimizing actual resources Transferability : The technology and protocols are available to all in the Basque Country. Conclusions : Our multipronged strategy demonstrated its efficacy to manage better patients with high rates of readmissions or those with dependency (at home and nursing homes). Discussion : A unified clinical history accessible to all the agents involved and improving the communication channels would make the strategy more efficient. Lessons learned : Training both patients and professionals and accessibility to the health system are the main keys in the future to manage multi-pathological patients.
关键词：multi-pathological ; new technologies ; multipronged strategy
