Abstract

ORTEGA MATAS, M.ª Cristina et al. Proactive intervention from a geriatric unit in complex chronic patient's care admitted to an acute hospital. Gerokomos [online]. 2014, vol.25, n.4, pp.152-158. ISSN 1134-928X.  https://dx.doi.org/10.4321/S1134-928X2014000400005.

We establish the Complex Chronic Patient (CCP) Care Program within the framework of the Catalonia's 2011-2015 Health Plan, in order to respond to a profile of patients in situation of clinical complexity. The interdisciplinary social-sanitary geriatric functional unit (UFIS) of the Hospital Universitari de Bellvitge (HUB) has implemented a proactive intervention program for CCPs whose age is equal to or greater than 80 years. Objectives: To describe the methodology for identifying and addressing the CCP and the strategies adopted to ensure the comprehensiveness, integration, and continuity of care. To analyze and describe the parameters used for the Global Geriatric Assessment (CGA) of the CCPs served by our unit. Methodology: Computerized medical records help identify CCPs entering the HUB. GGA is implemented within 24 hours after admission in order to avoid complications during admission, to establish the most appropriate device at the time of discharge, and to ensure continuity of care. Results and conclusions: We assessed 97 patients between October 2012 and February 2013. They entered mainly through emergencies from home, and were autonomous or with mild dependence for basic daily living activities before admission, with good cognitive status. At discharge most returned home with a Preparation for Discharge Protocol (PREALT) to ensure continuity of care. This intervention aims to reduce re-admissions, facilitate the return home and avoid or delay the institutionalization of the patient.

Keywords : Complex chronic patient; interdisciplinary social-sanitary geriatric functional unit; global geriatric assessment; continuity of care.

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