Original Title: Mejora de la atención al paciente mayor con patología crónica

Authors' objectives: - Identify and analyse care models for elderly patients with chronic pathologies. - Propose alternatives to the current use of health and social services through contextualised, integrated modules, applicable to our environment.

Authors' results and conclusions: Based on the findings in the literature and through the contributions of panellists, the basic elements that should guide the organisation of the care for elderly and chronic patients were identifi ed as follows:the centrality of the patient/carer nucleus, favouring the active participation of the patient and enabling him/her to be cared for at home, the promoting/rehabilitating view of health oriented towards the functional recovery and quality of life of the patient, overall, proactive care for which Primary Care is the backbone, of an interdisciplinary nature, favouring coordination with specialist levels and the social environment and that uses uniform and broadly agreed tools for the registration of actions, appraisal, referral, etc.Likewise, the most appropriate organisational models for our environment were put forward and prioritised, taking pertinence and feasibility criteria into consideration and placing these into context in accordance with the criteria of the panellists: Among the most significant of these models we should mention the «outpatient geriatric evaluation» and «continuous home care» linked to Primary Care. The pertinence and feasibility of «medium-stay hospitals» was also emphasised and, thirdly, «post-discharge care». On a second level of priority, a number of other models appeared, whose contributions were also considered to be of interest. This group would include «day centres», «home hospitalisation units» and the necessary contribution of «short-stay hospitals.

Authors' recommendations: In line with the conclusions set out above, a number of specifi c recommendations are made with regard to care management, training and research. For management Three organisational actions/modes are put forward, the development of which is considered to be pertinent, feasible and a prime objective in this field: - Reorganise and reinforce Primary Care teams. - Reinforce the funding of «medium-stay hospitals». - Reinforce, formalise and systematise «post-discharge care». At a secondary level, a number of other organisational options are considered. These appeared to be interesting but with a diff erent priority level and were assigned to diff erent areas: - Reinforce the complimentary role of «geriatric day hospitals/day centres». - Reinforce and expand the current «home hospitalisation units». - Create the fi gure of the referral hospital professional in «short-stay hospitals». - Promote the development and funding of tools and methodologies that improve the management and coordination of care for this group of patients. For teaching - Specifi c training of the professionals involved. - Need for personnel trained in geriatrics and gerontology. For research - Include the viewpoint of patients and carers. - Assess the implementation of the proposals identified. - Assess the effi ciency of the organisational proposals to be implemented.

Authors' methods: Systematic review of the scientific evidence relating to the first objective. With regard to the second objective, a qualitative technique of consultation and consensus was drawn up with a group of 30 experts, using the modifi ed two-round Delphi technique. By means of this technique, the pertinence and feasibility of the contextualised implementation of the diff erent organisational modes considered was analysed and an order of priority was established for these.

Project Status: Completed

Year Published: 2009

URL for published report: https://www.euskadi.eus/contenidos/informacion/2009_osteba_publicacion/es_def/adjuntos/D_09_01_mejora_atencion.pdf

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: <p>Basque Office for Health Technology Assessment (OSTEBA)</p>