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Context : In most developed countries, there is an increase of frail elderly people who are frequent users of health and social resources, often in an unplanned way. Recently, because of sustainability, there has been a significant reduction in acute hospital beds. These two phenomena have led to a saturation of the emergency services and increased the need for a new organizational model. This problem needs to be approached in a systemic way, by viewing it as a problem of the health system as a whole, not just as issue for emergency departments. To address the growing demands on the health system, the government has devised a system of pathways through the health service for the most frequently occurring medical needs of the population, for example, diabetes and, in relation to this paper, a complexity pathway. This involves the identification of patients and the development of treatment plans, and at the same time the reorganization of services to provide care in the most coordinated way possible. This paper aims to describe how an emergency service has been reorganized in the context of a complexity pathway through the health system and what impact it has had on the rate of hospitalizations and alternatives to hospitalization. Organizational changes : - Proactively detect patients who may be candidates for alternatives to hospital from the emergency department: patients already marked as complex from the community (use of territorial information systems), patients from nursing homes, patients who consult for a geriatric syndrome and patients aged over 85. - Involve all emergency service professionals through training in how to approach this demographic group. - The hospital management believes it is a strategic project. - Introduction of a short geriatric assessment in casualty departments. - Having a nurse practitioner who participates in the evaluation and management of cases and in coordinating all related intermediate care. - Having access to consultations with geriatric professionals from the acute geriatric unit or intermediate care units. Results in patients. - Up to October 2015, 437 patients were referred from emergency to intermediate care resources. 302 in the programme of sub-acute care and 135 in the hospital at home programme. - These patients are on average 81 years old, have a Barthel baseline of 61 and a high prevalence of geriatric syndromes. - The patients referred to sub-acute care had lower Barthel baseline and were classified as MACA (advanced chronic disease). Dementia diagnosis was more common. - This project has reduced the admissions in acute care of persons over 85 by 15% during the last two years. Conclusions : - Many patients were referred to hospitalization alternatives after applying this methodology. - The alternatives to hospitalization from casualty are allocated to people over 80 with a high level of frailty (geriatric syndromes, disability, advanced disease situation). - Patients have different characteristics according to which alternative they are referred to. - Hospital admissions of people > 85 to the acute hospital unit were reduced. - The participation of the nurse practitioner is the key to achieve good coordination with intermediate care.

Changes in emergency services to adapt to the complexity pathway within the health system