Volume 159, September 2025, 105384Author links open overlay panel, , , , , Highlights•

Case management: identification, engagement and care planning steps.

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Case management is rooted in multi-disciplinary communication and teamwork.

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The intervention of Case Management had a significant effect on reducing hospital admissions.

AbstractBackground

Chronic diseases are the most frequent health problem in the population. The development of case management, as an advanced care practice, is a basic strategy in the care of complex chronicity. The Catalan Health Plan establishes general guidelines for chronic care, linked to the role of the nurse case management.

Objective

The objective is to analyse the impact on the health system of shared monitoring, by the chronicity care team and its primary care reference team, in patients identified as complex chronic diseases (CCP) or with advanced disease (MACA), in regarding hospital admissions.

Methods

Retrospective quasi-experimental intervention study, with pre-post analysis, comparing each patient one year before and one year after being incorporated into the case management portfolio of a team made up of 14 nurses, 2 family medicine specialists and one social worker, with attention 365 days a year, 24 h a day.

Results

Regarding the decrease in hospital admissions, an average decrease (2013–2021) of 56 % was observed for MACA and 53 % in CCP. Statistical analysis based on a Poisson regression model with offset demonstrates that the intervention program had a significant effect on reducing hospital admissions, from a team formed from primary care itself.

Conclusions

The organization and structure of a chronic care team such as the one described, in an integrated manner with other levels of care, allows for a significant reduction in hospital admissions.

Section snippetsBackground

Demographic changes over the past 20 years and projections for the next 30 years indicate that the twenty-first century will be a century of population ageing, as the number of older people in the world's population will continue to increase [1]. Life expectancy in Catalonia is one of the highest in Europe (85.9 years for women and 80.4 years for men) [2] This ageing means that chronic diseases are very frequent, as well as comorbidity, complexity, frailty and unwanted loneliness [3].

Chronic

Study design

Retrospective study of quasi-experimental intervention, with pre-post analysis, comparing each patient one year before and one year after being incorporated into the CM portfolio, this was the best method for analyzing the data obtained, given that the study design was done after the fact.

Setting

The study area of this project is the southern metropolitan area of Barcelona, with an assigned population of 435,000 inhabitants (as of December 31, 2023); In this area there are 20 primary care teams, 3

Statistical analysis

The study will include all patients who in the study period from January 2014 to December 2021 were in the case management program. For the statistical analysis, data available in the primary care electronic medical record were used, pseudo-anonymized. Missing data are due to a lack of registration. Statistical analysis was performed using SPSS v21, using Poisson regression with offset.

Intervention description

People who are included in the CM portfolio receive close monitoring for symptoms that decompensate their primary pathology. They receive health education to prevent and respond to the first signs of decompensation. They are seen weekly during the stable phase and daily when decompensation occurs. An Individualized and Shared Intervention Plan is agreed upon with the patient, and a comprehensive geriatric assessment, social intervention, and medication review are primarily provided.

The

Results

In the cumulative data for the period studied, a total of 20,030 patients were identified: 15,046 as CCP (75 %) and 4985 as MACA (25 %). Of these, 3306 (16.5 %) had entered the CM portfolio for at least 15 days; Therefore, they are the patients on whom this study is based, they had an average age of 81.7 years, of whom 53 % were women. They were identified as 2546 CCP (63 %), 1472 MACA (37 %). The results by pathology showed that 46 % from heart failure, 46 % from respiratory disease, and 42 %

Discussion

The percentage of patients is 75 % of CCP compared to 25 % of MACA is related to the prevalence of both patient profiles, which in population represent 3.5 % of CCP and 1.5 % of MACA according to the guidelines of the Department of Health of the Generalitat of Catalonia. However, at the time of introducing them into the portfolio, the percentage is the same, going to 61 % for CCP and 39 % for MACA.

This chronic care team has a higher volume of patients than other nearby teams, and even in other

Conclusion

The organization and structure of a chronicity care team such as the one described, in an integrated manner with the rest of the care levels, allows a significant reduction in hospital admissions.

CRediT authorship contribution statement

Jesús Antonio Vaquero Cruzado: Methodology. Nuria Gutiérrez Jiménez: Writing – review & editing. Laura Carrillo Ciércoles: Writing – review & editing. Eva García Tarrida: Investigation. María Jesús Megido Badía: Methodology. Nuria Fabrellas Padrés: Supervision, Writing – review & editing.

Declaration of competing interest

None.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References (13)J. Garces et al.Case management as a methodology for the connection of health and social systems in Spain

Prim Care

(2015)

A.C. MediciHealth sector challenges and policies in the context of ageing populations

Dep Econ Soc Aff U N

(November 2021)

Life expectancy at birth. Catalonia. From 1981-1985 to 2018-2022. Available atESCA 2017 presentation. 2018-06-11Department of Health; TERMCAT, terminology centre. Chronicity terminology [online]. Barcelona: TERMCAT, Centre de Terminologia, copC. HamThe ten characteristics of the high-performing chronic care system

Heal Econ Policy Law

(2010)

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