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Evaluation of a patient-centered integrated care program for individuals with frequent hospital readmissions and multimorbidity

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Abstract

Managing patients with multimorbidity and frequent hospital readmissions is a challenge. Integrated care programs that consider their needs and allow for personalized care are necessary for their early identification and management. This work aims to describe these patients’ clinical characteristics and evaluate a program designed to reducing readmissions. This prospective study analyzed all patients with ≥ 3 admissions to a medical department in the previous year who were included in the Internal Medicine Department chronic care program at the Lucus Augusti University Hospital (Lugo, Spain) between April 1, 2019 and April 30, 2021. A multidimensional assessment, personalized care plan, and proactive follow-up with a case manager nurse were provided via an advanced hospital system. Clinical and demographic variables and data on healthcare system use were analyzed at 6 and 12 months before and after inclusion. Descriptive and survival analyses were performed. One hundred sixty-one patients were included. Program participants were elderly (mean 81.4 (SD 11) years), had multimorbidity (10.2 (3) chronic diseases) and polypharmacy (10.6 (3.5) drugs), frequently used the healthcare system, and were highly complex. Most were included for heart failure. The program led to significant reductions in admissions and emergency department visits (p = .0001). A total of 44.7% patients died within 1 year. The PROFUND Index showed good predictive ability (p = .013), with high values associated with mortality (RR 1.15, p = .001). Patients with frequent hospital readmissions are highly complex and need special care. A personalized integrated care program reduced admissions and allowed for individualized decision-making.

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This material is the authors' own original work, which has not been previously published elsewhere. The paper is not currently being considered for publication elsewhere. The paper reflects the authors' own research and analysis in a truthful and complete manner. The results are appropriately placed in the context of prior and existing research. All sources used are properly disclosed (correct citation).

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No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript.

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Authors and Affiliations

  1. Department of Internal Medicine, Lucus Augusti University Hospital, SERGAS, 1 Ulises Romero Street, 27003, Lugo, Spain

    Juan Carlos Piñeiro-Fernández, Álvaro Fernández-Rial, Roi Suárez-Gil, Beatriz García-Trincado, Adrián Suárez-Piñera & Emilio Casariego-Vales

  2. Case Manager Nurse, Medical Day Hospital, Lucus Augusti University Hospital, SERGAS, Lugo, Spain

    Mónica Martínez-García

  3. Clinical Epidemiology and Biostatistics Research Group, A Coruña Biomedical Research Institute (INIBIC), University of A Coruña, A Coruña, Spain

    Sonia Pértega-Díaz

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  1. Juan Carlos Piñeiro-Fernández
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Correspondence to Juan Carlos Piñeiro-Fernández.

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Piñeiro-Fernández, J., Fernández-Rial, Á., Suárez-Gil, R. et al. Evaluation of a patient-centered integrated care program for individuals with frequent hospital readmissions and multimorbidity. Intern Emerg Med 17, 789–797 (2022). https://doi.org/10.1007/s11739-021-02876-9

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