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The increasing ageing population has led to a proportional increase of people with chronic diseases, which has required implementing alternative models to conventional hospitalization in the order to be able to respond. Patients with chronic diseases with present imbalance that require hospital care without complex diagnostic technology can be treated in less intensive intern units. In Catalonia, in the order of 22% of chronic patients live in nursing homes. These people have constants health decompensations and they require continuous derivations to hospitals for emergency services. This could be mean that the person has to wait long hours to be assisted, in situations of discomfort and with plans focused on the disease and not in the person. Description: The unit of sub-acute care (US) Health of Sociosanitari Vallparadis (SSV) is an integral and cross-cutting assistive medical facility of intermediate hospitalization. The ultimate goal of the program is to improve the chronic patient care complex in the context of integrated care and reducing the frequency of emergency unit visits. Casa Vapor Gran (CVG) is 131 nursing home places where lives elderly people who may present different pathologies consequent derivations to emergencies service. SSV and CVG belong to the same company (Fundacio Vallparadis) and are located 500 meters from each other. On September 2015 was settled a direct derivation circuit between CVG and SSV for people who live in CVG and have a chronic decompensated disease and require healthcare. Circumstances of entry: 1. Admission of patients undergoing direct decompensation. 2. Transfer the patient to SSV from emergencies service. Aims: • Improve care for people who live in Casa Vapor Gran with chronic diseases, in the context of a comprehensive and integrated care. • Avoid frequenting emergency services to those users. • Promote the adequacy of resources and efficiency of the health system. Targeted population and stakeholders: People who live in Casa Vapor Gran with chronic diseases. Timeline: September 2015 to September 2016. Highlights: 18 patients have been care, 56% direct from CVG and the 44% transferring the patient from emergency service. The most frequent diagnosis have been congestive cardiac insuffiency (27,8%) and pneumonia (27,8%). The average stay has been 9,6 days. They return to CVG in the 83,4% of cases, with a mortality rate of 11,1%. A user satisfaction survey that assesses a global item, resulted in score of 3,64 over 4. Comments of sustainability: It’s a more efficient resource, because there is a holistic care as these patients needs with expenses lower than those generated in the hospital environment. Comments of transferability: It’s an example of coordination and transferability between health and social services. Conclusions: The program of chronic patient coordination created between CVG and SSV has shown to be effective, involving an integral and multidisciplinary attention to the users of a high perceived quality among the patients and their families. It represents an example of an integrated care in the current change of care model and organized, prioritizing persons in an efficient model of quality.

Integration of resources for the improvement of attention to people with chronic diseases at nursing home