The community heart failure program of the ICS Metropolitan Area South manages to reduce the number of hospitalizations by 50%

 

The joint work of primary and hospital care significantly improves the follow-up and control of patients 

 

 

The implementation, at the end of 2016, of the Territorial Program for Integrated Care for Patients with Community Heart Failure of the Southern Metropolitan Territorial Management of the ICS has resulted in a 50% reduction in the number of hospitalizations, according to recent data given to learn about the Modules for the Monitoring of Quality Indicators (MSIQ) of the Catalan Health Service.

The program is made up of professionals from the Multidisciplinary Unit for Community Heart Failure Care (UMICO) of the Hospital de Bellvitge, with specialists in Cardiology, Internal Medicine and Emergencies, as well as specialist professionals from Primary Care Hospitalet Sur, Hospitalet Centro and the Prat de Llobregat, both from the primary care centers and from the Functional Unit for attention to Chronicity and Complexity. All of them work integrally in the diagnosis, treatment and follow-up of patients with heart failure in this territorial area.

MSIQ data also show that, between 2016 and 2019, readmissions of heart failure patients during the first 30 days in this area have decreased from 17% to 9%, while avoidable hospitalization ( relative index that takes into account readmissions and first hospitalizations combined) has been reduced by 40%.

This program, which has shared leadership between the hospital and primary care, is coordinated by Dr. Josep Comín, head of the Cardiology Service of the Bellvitge University Hospital, and Ms. Coral Fernández Solana, attached to the Department of Attention South Metropolitan Primary. It is based on maintaining continuity of care between the hospital and primary care, placing special emphasis on the joint approach of cases and paying special attention to follow-up during the first days after discharge, which is when the risk of relapse is higher. In addition to the conventional healthcare activity, it includes interventions such as coordination at discharge, the provision of advanced practice at home, comprehensive follow-up to detect frail patients early, or actions for education and co-responsibility of the patient, among others. These actions are led by the nursing professionals of the program.

It also stands out for innovative initiatives such as telemedicine monitoring of patients. It has promoted the Hermes clinical trial, the largest ever undertaken in Spain on the application of mobile telephony in medical practice. Along this same innovative line, it will soon develop a project for the digital transformation of its activity that is expected to have an impact on a further improvement of the indicators.