Preventive Care Clinical Trial
Official title:
Impact of a Proactive and Integrated Health Intervention Between Different Assistance Levels Over Some Indicators in the Care of Chronic Complex Patient (CCP)
The aim of this study is to assess the effectiveness of proactive and integrated healthcare program for chronic complex patients (CCP). This program are based in coordination the primary level of attention with and speciality level. The objective is reducing hospital readmissions and know the benefit in total cost of care in 4 month before and 4 after intervention.
Quasi-experimental study with single-arm (pre-post study design without control group). The
investigators checking pre and post intervention the effectiveness of a healthcare program
for CCP. The interventions consist:
1. - Help the nurse in the hospital to carry out the care plans and the continuity care
report.
2. - Refer patients to the social workers.
3. - Collaborate with the social worker to refer to centers of media, long stay and
reference hospital.
4. - Ensure the follow-up appointments for the CCP.
5. - Make proactive calls to the CCP and/or their caregiver after discharge
6. - Plan the hospital discharge 48 hours in advance, so that the family and the patient
can be organized.
The investigator analysed if with this program, the CCP reducing hospital readmission and
reducing the Hospital expenditure.
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