Two years of operation of the COMPARTE care programme for complex chronically ill patients/Dos años de funcionamiento del Programa para la Atención de Pacientes Crónicos Complejos COMPARTE

Chronic diseases (CDs) are a priority health problem. These are conditions that healthcare is not able to cure, and for patients they mean a progressive deterioration of their health and loss of independence. Their prolonged and unpredictable course leads to a loss in quality of life and high use of healthcare and social resources. Since April 2009, our hospital (San Juan de Dios de Aljarafe Hospital) and its catchment area (Aljarafe Health region) have operated a specific programme to provide integrated and longitudinal care. Description of the intervention


Introduction
Chronic diseases (CDs) are a priority health problem. These are conditions that healthcare is not able to cure, and for patients they mean a progressive deterioration of their health and loss of independence. Their prolonged and unpredictable course leads to a loss in quality of life and high use of healthcare and social resources. Since April 2009, our hospital (San Juan de Dios de Aljarafe Hospital) and its catchment area (Aljarafe Health region) have operated a specific programme to provide integrated and longitudinal care.

Description of the intervention
The objective of our programme is to promote home monitoring of CDs and improve patient quality of life. The programme aims to achieve the aforementioned objectives through the development of three areas: scientific and technical services; social and family care; and the coordination of care and safety. Across these areas, there are six main lines of development: stratification of patient risk; comprehensive assessment of patients (clinical, functional, psychological and social and family); provision of pharmacological treatment and care based on the best available evidence; self-care education; sustained coordination of care; and development of professional skills. These lines have been translated to 11 operational interventions: patient identification; integrated assessment and care; standardisation of procedures; rational use of medicines; self-care education; sectorisation of the inpatient and outpatient areas; transfer on discharge; linkage to electronic health records; follow-up in primary care; close observation to detect exacerbations; and development of professional skills. Currently, the programme is applied in the case of patients with heart failure, chronic obstructive pulmonary disease, multiple diseases, or cancer requiring palliative care. A multidisciplinary group of health professionals (general practitioners, and specialists, nurses from both levels of health care, social workers, IT specialists, etc.) participated in the establishment and implementation of the programme.

Results
A total of 1308 patients have participated in the programme so far. Of these, 36.4% were included because they had multiple conditions, 30.8% for being readmitted, 22.4% for being classed as frail (following the criteria of the Department of Health of the regional Government of Andalusia [1]), 7.7% for having chronic respiratory disease, 8% for having heart failure and 2.7% because they required palliative cancer care. The average hospital stay that preceded inclusion on the programme was 9.04 days in 2009 and 10.37 days in 2010 (p=0.018). Most patients received a standard care plan during their hospital stay. Further, the main caregiver was given training in 40.5% of cases, while 8.1% of patients received direct training. The mortality rates in the hospitalisation episode were 18.6% in 2009 and 16.7% in 2010 (p=0.378). With regards to readmissions, 20.4% of participants were readmitted in 2009, while this rate fell to 10.7% in 2010. The inclusion criteria were similar for patients who were readmitted and the other participants. The mortality per episode was higher (35.89%). Once the programme was introduced, the average number of admissions was 1.5 among patients who were readmitted.
We highlight the falls in the demand for emergency services in primary care and in the number of GP consultations, by 6.5% and 7.2%, respectively, in 2010 compared to the previous year. The results of the evaluation of the activity in primary care are: 70% of patients were visited at home by their doctor and/or nurse and 33% received a joint visit within the agreed time frame (first 48-72 working hours).

Conclusions
The programme aims to provide a multidisciplinary approach and integrated healthcare for patients with CDs. It has made it possible to reorganise and rationalise our resources. In addition, it promotes continuity between the different levels of care as well as patient safety. Patients and caregivers have become more involved in their own disease and care. The lessons learnt are that it is worth striving to promote team work as it can improve sometimes complex care by sharing the provision of care and it allows the transfer of this innovative experience to other areas of action, producing favourable health outcomes.