Managing Integrated Care in Nursing Homes in Catalonia

摘要

Introduction : In our 200,000 inhabitants catchment area, north coast of Catalonia, 50km from Barcelona, you can find many Nursing Homes (2,000 beds). A 2006 study carried out by our organization, triggered by hospital admissions rising in elderly, showed that hospitalization rate in patients over 84 was 12.5% higher than Catalonia average and the percentage of emergency room admissions was twice the Catalonia average (4.75% vs. 2.4%). The 35% of hospitalizations came from Nursing Homes in this age group and they had a higher severity and longer length of hospital stay. Nursing Homes are typically under resourced, short-staffed and high turnover due to a highly demanding and poorly paid work weak acknowledgement. The study also found the staff had insufficient skill and knowledge to assess and manage common acute symptoms and chronic diseases crisis or palliative care. The primary care team assigned to these facilities in general didn’t know the residents and their role were purely administrative responding to basic requirements from Nursing Homes like transcribing prescriptions. Polypharmacy was common in these patients with an average of 126 prescriptions per person and year. Objectives : -To improve health care for the catchment population -To reduce the number of hospital admission and polypharmacy -To improve coordination between Nursing Homes and Health Care services and other clinical consultants -To unify criteria for the care of these patients Intervention : In 2007 a Support Team formed by a physician and a nurse, both trained in geriatrics, took charge of all the patients from the Nursing Homes in the catchment area of the Primary Health Care Centers managed by our organization (12 Nursing Homes, 981 beds). The rest of the Nursing Homes of the area who were receiving Primary Health Care from centers managed by another Heath Care provider (15 Nursing Homes, 1031 beds) continued to receive the usual primary care and served as a control group. The main roles of the Support Team were: -Offer comprehensive geriatric assessment, additional tests and treatments in Nursing Homes avoiding the reference of the residents to other health structures -Provide assistance to Nursing Homes staff in monitoring complex cases and palliative care -Standardize health care based on clinical practice guidelines -Case management and coordination across levels -Check and adjust drug treatment together with Nursing Homes staff. -Specialized training to Nursing Homes staff on how to avoid hospitalizations by using early interventions Results : In the Nursing Homes where the intervention was carried out: -Emergency room admissions dropped by 43% (1,069 in 2006 to 610 in 2014) -Hospital admissions fell 41% (437 in 2006 to 258 in 2014) -Polypharmacy decreased, 35% less prescriptions per bed (126 in 2006 to 82 in 2014) In the control group, there were not significant changes Discussion and conclusions : People living in Nursing Homes are elderly with high levels of dependency and increasing complexity health care requirements. The Health Care System and Nursing Homes have to adapt themselves to meet the growing needs of this group of population. Therefore, it is essential to include these facilities in territorial health care strategies, as well as a close cooperation and coordination between Nursing Homes and the different levels of health care, in order to provide effective and efficient care to this population. Despite the initial reluctance of some Nursing Homes to accept the Support Team activities, nowadays there is a close work between them since a complementary care is offered, resulting in a better care of the residents. Our model of integrate care has been acknowledged by the Agency for Innovation and Evaluation of Quality of Health Services in Catalonia (AQuAS) who identifies experiences which have a positive impact on strategic lines of Health System that can by in the futur implemented throughout the territory. Considering the results obtained, we can conclude that it is possible to improve care for people living in Nursing Homes through the involvement and cooperation of these facilities and territorial Health System.