Chronic and complex patients

//The Parc Sanitari Sant Joan de Déu introduces a specific chronic care programme

There have always been chronic and complex patients. However, in recent years, this category has been conceptualized, probably because the number of chronic patients is increasing, along with their impact on the health care service. Due to population ageing, prevention policies must be strengthened to try to reduce the number of patients, and the severity of disease, which will increase as human life expectancy rises. In addition, the current health care model has to be revised and adapted to the needs of an ageing population.

Chronic patient care must be central to any health plan for the coming years. The Catalan health system has already introduced strategies aimed specifically at caring for people with multimorbidity, such as the Chronic and Complex Patient Care Programme (PACC). The General Hospital of the Parc Sanitari Sant Joan de Déu (PSSJDD) is one of the first centres to implement the programme. The results have been outstanding: the number of patients the hospital sees has dropped notably, as has the length of hospital stays.

The complex chronic patient)

The group of patients that might be described as complex chronic patients (CCP) currently comprises between 3 and 5% of the population, and consumes 65% of health resources. It is made up of people who suffer from various chronic diseases or just one. Their clinical condition is serious and ongoing, and involves failure or dysfunction of an organ or system, for example heart or kidney failure, dementia or depression. The group also includes patients who do not meet these criteria, but are affected by other clearly complex conditions, such as schizophrenia or mental illnesses with behavioural disorders.

Some factors increase the risk of becoming a CCP, including obesity, loneliness, institutionalization or a low social, cultural and economic level. Normally, the process involves a gradual loss of independence that can lead to dependence and have an impact on emotions, family and work. The prognosis is often poor. CCPs tend to have numerous symptoms that are difficult to control, and their clinical condition changes over time. Consequently, chronic patients need to be monitored continuously, and their treatment must be adapted to each variation in their state of health.

CCPs are characterized by their recurrent use of health services and by multiple hospital admissions

In terms of their relation to the health system, CCPs are characterized by their recurrent use of health services (primary, specialized, and emergency care) and by multiple hospital admissions, in some cases for long stays. Chronic complex patients require care from a combination of professionals, need to undergo numerous diagnostic tests, and are prescribed a range of drugs. They have low adherence to treatment, and the drugs may have side effects or interact. In addition, patients’ social and economic situation has a great impact on how the disease evolves.

To improve care for those who use the health system so regularly, the PSSJDD General Hospital has introduced a programme for complex chronic patients. The idea is to ensure that patients remain in their natural environment, by mainly providing care in their homes or in primary care centres. If the coordination between different levels of health care is optimized and the fragmentation of the process is reduced, the system can become more comprehensive, dynamic, cost-effective and efficient. The goal is to avoid non-scheduled hospital visits and hospitalization, and thus reduce the impact of the high prevalence of diseases that require many treatments and consume a considerable amount of resources.

Case management

The programme is based on the “case management” method, which consists in individually monitoring CCPs in hospital, from the time of admission to discharge, whether they return to the community or have been provided with a health care resource. The manager checks how many patients with complex and chronic characteristics there are in the hospital, consults the clinical information on each patient and the personalized joint care plan (PJCP) created by the primary care team, and sees the patients. Depending on his/her assessment, and together with the doctor, the manager decides whether each patient should be hospitalized at the centre, treated at home or discharged.

If the patient returns home, the chronic primary care team is notified and the patient is seen regularly to ensure that there is a continuum of care. The chronic care team visits the patient’s home to supervise the treatment and check progression, and patients only have to travel to the hospital for periodic check-ups. CCPs have a telephone number that is staffed twenty-four hours a day, every day of the year. If they have any problems, they can call and the manager will try to resolve their problem in conjunction with the GP, the referring doctor in the management team or hospital doctors.

Admissions of chronic patients have dropped by 60.51% and hospital stays by 61.15 %

The PSSJDD launched the programme in 2012. Since then, admissions of chronic patients have dropped by 60.51% and hospital stays by 61.15 %. These kinds of strategy improve the quality of care for chronic patients and their quality of life, as unnecessary trips to the hospital, time in waiting rooms, and institutionalization are eliminated. In addition, as patients are visited and evaluated continuously, they feel better protected. Finally, the system involves each patient in their own treatment; and it also gives an important role to the patient’s carer and family, who have the satisfaction that the care they provide altruistically is being recognized.


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