An adaptive case management approach to prevent unplanned hospital admissions in a care continuum scenario
[eng] Unplanned hospital admissions generate high economic, and organizational, burden on healthcare systems worldwide. Likewise, inpatient care has a deleterious impact on patients’ quality of life and is a well-demonstrated causal factor of nosocomial complications. Moreover, multiple admissions h...
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| Tipo de recurso: | tesis doctoral |
| Estado: | Versión publicada |
| Fecha de publicación: | 2023 |
| País: | España |
| Institución: | Universidad de Barcelona |
| Repositorio: | Dipòsit Digital de la UB |
| OAI Identifier: | oai:diposit.ub.edu:2445/215620 |
| Acceso en línea: | https://hdl.handle.net/2445/215620 http://hdl.handle.net/10803/692290 |
| Access Level: | acceso abierto |
| Palabra clave: | Política sanitària Malalts crònics Cura dels malalts Medical policy Chronically ill Care of the sick |
| Sumario: | [eng] Unplanned hospital admissions generate high economic, and organizational, burden on healthcare systems worldwide. Likewise, inpatient care has a deleterious impact on patients’ quality of life and is a well-demonstrated causal factor of nosocomial complications. Moreover, multiple admissions have shown association with poor survival prognosis in chronic patients. Accordingly, there is a robust rationale to explore the potential of interventions aiming at preventing potentially avoidable hospitalizations, with an integrated, patient-centered, approach. Chronic patients with multimorbidity, and frailty, are the most frequent candidates for unplanned hospitalizations, either due to episodes of exacerbation of a chronic condition, or during vulnerable periods, like transitions after hospital discharge. The analysis of the literature on interventions to prevent hospitalizations in community-based chronic patients with episodes of exacerbation and on transitional care programs aiming at reducing early-readmissions after discharge provide inconclusive messages. This can be explained by several phenomena, namely: heterogeneities of the interventions, suboptimal description of the study protocols, poor comparability among sites, among others. The unsolved efficacy-effectiveness gap seen between the positive results of a two-center randomized controlled trial, carried out in Barcelona (ES) and Leuven (BE) in 2006 and the lack of effectiveness observed when the same intervention was replicated in a pragmatic randomized controlled trial conducted in Barcelona during 2015, was explained by three intertwined factors: lack of personalization of the intervention, insufficient management change and immature digital support. The current PhD thesis relies on the hypothesis that adoption of interventions properly addressing the three factors alluded to above, that is, personalization, management change and digital support, can generate value-based reductions of hospitalizations in chronic patients. The research reported in the thesis was undertaken in the context of the Catalan original Good Practice of the European Joint Action on implementation of digitally enabled integrated person-centered care (https://www.jadecare.eu/), an initiative launched to address core aspects of health system transformation in the European Union. It includes four studies addressing three main objectives. Objective 1 was the assessment of home hospitalization as a modality of care including transitional care after discharge. Home hospitalization was selected as a use case because it involves all stakeholders participating in prevention of hospitalizations and plays a principal role to foster vertical integration, between hospital and community-based professionals. The two studies carried out under the first objective cover a Triple Aim assessment with a Multiple Criteria Decision Analysis (MCDA) approach and a Cost-Consequence Analysis (CCA) of Home Hospitalization, respectively. The second objective explored the potential of Adaptive Case Management (ACM) for digital support of collaborative work across healthcare tiers aiming at stimulating share care arrangements between specialized and primary care, as well as between health and social care. Two specific interventions were piloted: prevention of severe exacerbations in community-based chronic patients and prehabilitation of candidates for major surgical procedures. A commercial solution, Health Circuit, for digital support was successfully tested. Within the third objective, a co-creation process using design thinking techniques and quality improvement methodologies, was undertaken, with participation of key stakeholders, including patients. The maim outcome was the design of a pragmatic study protocol for prevention of avoidable hospitalizations to be piloted within 2023 in a cohort of 200 multimorbid patients during a three-year follow-up period. Main conclusions of the PhD thesis are threefold. The ACM approach seems to constitute a suitable approach to achieve mature digital support on integrated care services, already demonstrated for prehabilitation. After appropriate testing, the pragmatic study protocol, generated during the co-creation process, aiming at early management of exacerbations and prevention of hospitalizations could become the basis for the design of future mainstream collaborative interventions across healthcare tiers. |
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