Demographic factors such as the dispersion of the population in certain areas of the province of Ciudad Real or the high level of aging favor the creation of specific health devices that allow care for patients with comorbidities or chronic pathologies, whose level of complexity requires coordinated care. and continues by the public health system.
Within this framework, the Integrated Attention Management of Manzanares has created the Care Continuity Unit between Primary Care and Internal Medicine (UCAPI) made up of an internist and a Nursing team that coordinate with the Primary Care teams for the joint management of complex chronic patients.
The creation of this device allows all those involved (Primary School Team and Hospital Team) to act proactively in order to avoid clinical decompensation for the patient that may imply repeated visits to the Emergency Department, as well as hospital readmissions, reported in a note from regional government press.
Cardiovascular diseases and specifically heart failure, together with chronic obstructive pulmonary disease, due to their prevalence, are the most common processes that are treated at the UCAPI, as well as patients with anemia, particularly iron deficiency, which worsens the basic processes of a chronic patient. In the case of elderly people, anemia is a common process and more so if there are kidney diseases.
This is how the referents of the UCAPI at the Hospital Virgen de Altagracia de Manzanaresthe internist Barbara Nieto-Sandoval and the Nursing team made up of Miracles Alhambra, Maria Bolanos y Ana Rosa Sanchez Maroto.
REFERRAL PROTOCOL
Specifically, for the implementation of this care circuit, located in the Polyvalent Unit of the Virgen de Altagracia Hospitala referral protocol has been designed in which the standard patient criteria are established, as well as a consultation line between Primary Care and Hospital professionals to facilitate immediate care.
A healthcare resource at the service of Primary Care The UCAPI is a “direct line of communication between the Primary Care specialists and the Internal Medicine specialists of the hospital”, explained Dr. Nieto-Sandoval.
The circuit is activated when the complex chronic patient goes to their health center due to some type of decompensation of their underlying pathology and it is the Primary Care professionals who contact UCAPI to expedite the referral and so that the patient can be stabilized in the unit , thus avoiding possible repeated admissions or multiple attentions in the ER.
At the UCAPI, he pointed out, “high-resolution outpatient care is carried out in the same morning and once the patient returns home, telephone follow-up by the Primary Care assistance team begins.” Thus, waiting is avoided or that the patient goes to the ER repeatedly due to decompensation.
COORDINATION WITH NURSING
The Care Continuity Unit is not only regarding fluid communication and interaction between Primary Care and Internal Medicine doctors, but also involves coordinating the Nursing teams of the health centers and the unit.
Nursing activity includes the application of intravenous treatments, as the case may be, such as diuretics, iron, transfusions or antibiotics, as well as performing other diagnostic tests such as blood tests, electrocardiograms and other nursing care, explained the Nursing team.
All this is added to the individualized monitoring of the processes, being the link with Primary Care, also helping in the orientation of care to the relatives and/or caregivers of these people, thus avoiding that the patients have to travel to the hospital.
