Improving healthcare at home for complex chronic patients (CCPs) in Andalusia (JADECARE pilot)

Abstract

Introduction: A Complex Chronic Disease is a condition involving multiple morbidities that requires the attention of multiple health care providers and, therefore, a holistic approach. 
 The Andalusian Public Health System is responsible for the provision of healthcare and public health services to the Andalusian population (8.5 million inhabitants), where around 200000 complex chronic patients (CCPs), with chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) have been identified and prioritized. Healthcare at home for CCPs is considered a key element that facilitates patient follow-up, can avoid emergency episodes, promoting patient empowerment.
 The Andalusian participation in the EU Joint Action JADECARE “joint action on implementation of digitally enabled integrated person-centered care” (GA 951442) focuses on improving healthcare at home for CCPs with CHF and COPD. The development, implementation and testing of a Centralised System for Proactive Follow-up (SCSP) of chronic patients is being monitored, as well as the tele-referral service which is being expanded. The SCSP is supported by National funds as well (Servicio para la implantación de una solución corporativa para el seguimiento proactivode pacientes crónicos en el sistema sanitario público de Andalucía (Expdte. 039/21-SP.).
 The aim of the JADECARE Andalusian pilot is to improve health status and quality of life of CCPs by enhancing home healthcare proactive follow-up and its evaluation.
 Method: The development, implementation and testing of the Centralised System for Proactive Follow-up of chronic patients within Andalusian Public Health System includes several steps, from tendering, SCSP design and development, to training and assessment.
 The SCSP will allow to gather information from home healthcare of CCPs integrated in the corporate IT system and EHR (Diraya). The platform will be a key element for healthcare professionals in the proactive and remote monitoring of chronic patients, allowing early identification of warning signs/signals, adaptation of prescriptions, anticipation of health problems, providing support to caregivers and avoiding unplanned inpatient episodes. This SCSP will be monitored as well as the tele-referral system for CCPs.
 
 Results, Conclusions and Lessons learned: Results of this pilot will be presented during the conference. Process, outcomes, patients’ satisfaction and technology acceptance model indicators will be measured.
 The SCSP is expected to facilitate patients’ follow-up, improving continuity of care by healthcare professionals and patients’ quality of life.
 Discussions: The Andalusian JADECARE pilot is aligned with the Andalusian Comprehensive Healthcare Plan for Patients with Chronic Diseases and the Andalusian Comprehensive Care Plan, and takes into account the experience of the “Digital roadmap towards an integrated health care sector”, from the Region of Southern Denmark.
 An integrated healthcare system linked to a solid corporate IT system allow the development of a Centralised System for Proactive Follow-up of chronic patients that leads to an improvement of patient care and quality of life while public healthcare resources are optimized.
 Limitations: Health outcomes assessment in the timeframe of the project.
 Suggestions for future research: Home healthcare monitoring assessment.