A program of care coordinated for patients with chronic illnesses get a 8.4% reduction in the number of annual hospital readmissions.

-The project aims the improvement of the quality of life of these patients

-also search care coordination at all levels, the involvement of all health professionals, improving the car care and pharmacological conciliation

-this program of coordinated care has allowed an estimated direct savings from 194.846 € to the health system in a year in your area implementation

Alicante, March 2012.- the coordination of health professionals is essential in the treatment of people with a chronic disease. And so it has highlighted the programme shares, a care project coordinated to patients with this type of pathologies whose results were presented last Friday 9 March in Alicante within the framework of the IV National Congress of the chronic patient care, organized by the Spanish society of internal medicine (SEMI) and the Spanish society of family medicine and Community (semFYC), together with the Ministry of health of Valencia, sponsored by ESTEVE and the collaboration of MSD, carbides medical, Sanofi and Telefónica.

This project demonstrates the importance of the introduction of models of coordination to improve the health and quality of life of these people, getting in addition to reduce health spending.

Thus, the development of the program has associated with a reduction of 8.4 per cent in the number of readmissions to the year for these pathologies and estimated savings of 194.846 €. Among the causes of these readmissions, the most frequent have been the decompensation of heart failure and COPD, the majority of them being pluripatológicos patients.

After the implementation of the programme, both doctors and nurses of primary care hospital care have expressed their overall satisfaction with the model of continuum of care and improvements that have taken place in the cooperation and communication among professionals in all areas ”, says Dr. Fernández Moyano, one of the coordinators of the project.

During the development of the programme have been a number of significant results such as the decline in the number of income of patients with chronic diseases.

A very important improvement in education in care auto margin, is also observed that the vast majority of the times has carried out by the primary caregiver.

The implementation of the programme shares

The idea of the program shares came out of the importance of addressing the needs of these patients, from a classical assistance based on the treatment isolated flare-ups of the disease, to a system coordinated between levels of care and apply clinical best practices that have demonstrated benefits. In this sense, the high number of readmissions occurring today is probably a result of a poor control of symptoms and poor health coordination ”.

To change this situation arose this project with several goals, being the main improve the quality of life of patients with chronic and complex diseases. As secondary objectives include: laminated the risk of re-entry of the sick, standardizing the implementation of plans of care and pharmacological treatments improve the rational use of medicines, establish a programme of education in self-care and introduce a model of care coordination involving all levels and health professionalsas well as developing competencies and professional roles with specific training.

The programme shares began between the Consortium public health of Aljarafe (Hospital San Juan from Dios of Aljarafe) and the sanitary district of primary care, in April 2009, on a previous developed model of care coordination. Patients that have been included are pluripatología, advanced heart failure, severe COPD or neoplastic disease in situation of palliative care.

For Dr. Fernández Moyano would be necessary to develop assistance programmes for people with chronic diseases, locally adapting already established health care recommendations. This implementation, should include specific objectives and common management structures between different social levels, implying in their development and results to patients, people, carers and professionals.