Redesigning the attention services to chronic patients according to their risk stratification

Resumen

Introduction: In Primary Care of the Community of Madrid Spain, the priority service offer is included in the Standardized Services Portfolio, which comprises up to 43 services. A third of them are aimed to the attention of chronic pathologies and they describe the healthcare process to be carried out, and represent a quality tool. However, up to now these services offered the same kind of care for any patient, regardless of its situation complexity.Description of policy context and objective: This project is part of the Care Strategy for patients with chronic diseases in our Community that proposes the need of developing a specific service offer for patients according to the intervention levels based on Kaiser Permanente Risk Stratification Model. These levels low, medium or high are assigned by the professionals who look after the patient. The intervention level is determined by taking as reference the population risk level given by the GMA tool and the professional point of view together with his knowledge about the patient ability to self-care and face the disease,occurrence of complications, etc.Objective: Redesign and homogenize the primary healthcare model by adapting the portfolio services to the three intervention levels.Targeted population: People diagnosed with chronic pathologies and specific medical coverage according to the healthcare designed in our portfolio.Highlights: The processes of attention to hypertension, Diabetes Mellitus DM, dyslipidemia, childhood and adult obesity, childhood and adult asthma, chronic obstructive pulmonary disease COPD, heart failure, ischemic heart disease IHD, dementia, care for the frail elderly, the immobilized and the patients with palliative needs, have been redesigned. The low intervention level includes annual activities based on organised education that promote self-care and desease self-management. The medium level includes biannual controls based on shared disease management beetwen patient and profesional. Medium level is the only level that existed in the previous Portfolio. Now, all chronic services include low and medium levels while the high level is only addressed to patients with DM, IHD, asthma, COPD, greaterneurocognitive disorder, serious functional disability or palliative needs. High level includes quarterly functional capacity assessment activities, tips to avoid fall down and to follow a healthy diet, monthly telephone contacts to detect emergency symptoms, home visits, education and support activities for caregivers. Likewise, the high level implies setting up coordination circuits with hospital care in order to avoid frequent visits to the emergency services and to facilitate care at the hospital when it´s necessary.Comments on transferability: This new design is fully transferable to any healthcare organization.Conclusions: The new services define an updated and novel way to care for chronic patients, because they differentiate not only clinical activities but also their implementation frequency. By prioritizing the attention to high complexity patients, we will contribute to both the optimization of the resources and to the care improvement. In this way, we will be able to anticipate functional deterioration, avoid complications, decrease premature mortality and improve the life quality of chronic patients and their caregivers.