Case Management for Patients with Complex Multimorbidity: Development and Validation of a Coordinated Intervention between Primary and Hospital Care

International Journal of Integrated Care

Bernardo Valdivieso-Martínez¹  María Soledad Giménez-Campos¹  Elisa Soriano-Melchor¹  Amparo Bahamontes-Mulió¹  Lucas Donat-Castelló²  Salvador Tortajada²  Julia Villar-López²  Juan M. García-Gómez³  Raquel Faubel-Cava⁴ 

[1] Hospital Universitario y Politécnico La Fe;Instituto de Investigación Sanitaria La Fe;Universidad Politécnica de Valencia;Universitat de València;

关键词: integrated care;    case management;    complex multimorbidity;    chronic patient;    hospital at home;   

DOI  :  10.5334/ijic.2493

来源: DOAJ

【 摘 要 】

In the past few years, healthcare systems have been facing a growing demand related to the high prevalence of chronic diseases. Case management programs have emerged as an integrated care approach for the management of chronic disease. Nevertheless, there is little scientific evidence on the impact of using a case management program for patients with complex multimorbidity regarding hospital resource utilisation.  We evaluated an integrated case management intervention set up by community-based care at outpatient clinics with nurse case managers from a telemedicine unit. The hypothesis to be tested was whether improved continuity of care resulting from the integration of community-based and hospital services reduced the use of hospital resources amongst patients with complex multimorbidity.  A retrospective cohort study was performed using a sample of 714 adult patients admitted to the program between January 2012 and January 2015. We found a significant decrease in the number of emergency room visits, unplanned hospitalizations, and length of stay, and an expected increase in the home care hospital-based episodes. These results support the hypothesis that case management interventions can reduce the use of unplanned hospital admissions when applied to patients with complex multimorbidity.

【 授权许可】

Unknown