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Piloting of the care project for chronically vulnerable patients begins at the health center

Ubeda's Virgen De Gavellar Hospital has initiated a project to improve the care of complex or vulnerable chronic patients through participation in health emergency 061 in Andalusia, and Primary Care.

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Piloting of the care project for chronically vulnerable patients begins at the health center

Ubeda's Virgen De Gavellar Hospital has initiated a project to improve the care of complex or vulnerable chronic patients through participation in health emergency 061 in Andalusia, and Primary Care. It is led by Nieves La Fuente (Director of the Andalusian Health Service Care Strategy), and aims to reduce hospitalizations and preventable readmissions.

This initiative is designed to improve patient health, reduce inappropriate emergency service use, and improve self-perception and quality of life. It also involves patients' families in decision-making, self-care, and participation.

Trinidad Rus, the territorial delegate for Health and Families visited the Ubeda health center, where the pilot project is underway. The operation of the first phase of the pilot is currently being tested with patients from the Northeast Health Management Area (Jaen) and District Sanitary Country Campina(Huelva). The person in charge for Care at the 061 Health Emergency Center was Rafael Munoz, Francisco Sanchez, the provincial director of 061 Jaen and Jesus de la Paz, the managing director of Northeast Health Area Jaen.

These centers' case managers have chosen patients with multiple pathologies (mostly heart failure or chronic obstructive lung edema) and have created a customized action plan to help them manage their pathological process.

They have been provided with a mobile app by the SAS that allows them to track their progress and add information. If registered values exceed normal ranges, the application will advise them to call the 061 Health Emergency Center at their particular telephone number to receive personalized attention.

The complex chronic program is identified by those who call the 061 centers to request assistance. A manager will first attend to the patient to determine if the situation calls for immediate activation of an ambulance team. It will also transfer the call to a nursing staff member of the coordinating centre, who will attend to the patient's needs and if necessary, a room physician.

If the phone service reveals that the health staff believes the patient requires face-to-face treatment, the coordinating centre will notify the local nursing team, who will then go to the patient's house as quickly as possible.

These patients receive assistance by phone or in person. This allows for continuity of care. It is possible that more than 200 000 patients will be able to join the Andalusian program, which covers 5% of Andalusian residents with complex chronic diseases.

The Primary Care EMCAs, or 061 advanced coordination team, is made up of a nurse professional and a health technician. They can quickly respond to patients suffering from diabetes, COPD, heart failure, and other chronic conditions. They assist patients in managing these situations and avoid them being transferred to the hospital.

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