Original Title: Desarrollo y pilotaje de un programa colaborativo multidisciplinar para la atención integral de pacientes diagnosticados de insuficiencia cardíaca (IC) PROMIC

Authors' objectives: • To collate current knowledge in this field by way of a comprehensive literature search. • To understand the opinión of the professionals involved in the process using discussión and consensus methods in order to design the most effective and comprehensive clinical and organisational intervention. • To gain a better understanding of patients diagnosed with heart failure in order, as far as possible, to orient our interventions on the basis of their preferences. The goal of this project is to establish a sustainable care model for patients admitted with HF that improves their health outcomes. The understanding gained during implementatión of this model will lead to further research involving the care of other types of complex chronic patients.

Authors' results and conclusions: The literature review showed the effectiveness of HF programs (evidence level A) and, to a lesser extent, that of care management programs in comorbid patients. There is some evidence that a higher degree of multidisciplinarity results in better team coordinatión and training and more effective care for complex high-risk patients, of which HF patients are a good example. In light of the review, a program that represented a structural (as regards the cross-level organisation and coordinatión of care devices) and responsibility change, with special emphasis on the new nursing roles and supported by activated and more self-reliant patients who are better able to care for themselves, thereby converting clinicians into genuine agents for change. The final phase of the project involved piloting the interventión designed in 15 polymedicated (mean of 11 drugs) patients admitted with HF and multiple comorbidities (mean of six chronic diseases) to confirm its feasibility. This pilot study concluded with positive results and led to the implementatión of a quasi-experimental phase II trial. CONCLUSIONS AND RECOMMENDATIONS PROMIC is an organisational care management innovatión that provides a comprehensive and integrated approach to patients with a high degree of complexity, in this case patients admitted with HF. It promotes the integratión of care in different healthcare settings with the changed role of nurses and self-care training in patients. As such, PROMIC helps to ensure the continuity of patient care in their own environment. The aim of the innovative care model that PROMIC is intended to provide in high-risk HF patients is to improve health outcomes and to modify the current care model for chronic diseases, thereby serving as the foundatión for future interventions targetting other chronic patients with multiple comorbidities and complex needs. The solid and comprehensive training received by nurses results in a clinical assessment adapted to the degree of comorbidity and optimisatión of the drugs administered according to protocols and clinical practice guidelines. The family doctor, with training and dedicatión based on the needs of his patients, concentrates on comprehensive patient care as regards the complex comorbidity, the early treatment of different types of decompensations and home-based care. The cardiologist helps to adapt the care of HF and cardiovascular (CV) comorbidities. This project has allowed various aspects that still need to be taken into account to be identified. One such aspect is the need to promote links between the patient and community resources and to improve communicatión and coordinatión with the services that supply such resources. The difficulty experienced by this type of patient in accessing social resources as a result of their emergency and programmed needs has been identified. A further aspect to be considered is the possibility of evaluating the quality of life of carers and the cost utility of the intervention. As various gaps in the understanding of how best to manage HF patients with various comorbidities have been detected, the drafting of a guideline in this sense has been proposed as a future challenge for the working team. Indeed, precisely due to the presence of comorbidities in this type of patient, we consider coordinatión with consultants from other specialities to be essential. One of the main drawbacks identified during implementatión of the PROMIC project is the need to manage patient informatión in a single case history that can be accessed by all professionals involved in patient care. As HF patients present marked comorbidity, we expect that the experience acquired during this project will help us to design interventions that can be broadened to cover all complex chronic patients likely to benefit from a care management program. We have encountered difficulties in finding professionals willing to take on these new roles due to the lack of incentives and their higher demands. Finally, we note that working times and workloads need to be established and absences need to be covered by qualified staff in order to maintain the effectiveness of the intervention.

Authors' methods: PROMIC is an organisational innovatión comprising a complex interventión containing components supported by scientific evidence from both a content (based on clinical practice guidelines, CPGs) and organisational viewpoint, as well as regarding its implementation, which is based on the Chronic Care Model (CCM), a chronic disease management model developed by Ed Wagner at the McColl Institute (Seattle, USA) in the 1990s. As this is a complex intervention, we have selected the theoretical and methodological framework for the design and evaluatión of complex interventions in a clinical setting developed by the healthcare and public health services working group of the UK Medical Research Council (MRC), which comprises four phases. In phase 0 we have undertaken a strategic needs research and evaluatión process and a comprehensive literature search regarding the management of HF patients and complex chronic comorbid patients in order to identify and select areas for optimisation. Phase 1 comprised design of the interventión program in collaboratión with professionals from the fields of primary (PHC), hospital-based and social care, as well as PHC researchers and managers, taking into account the actual context. Interventions were performed in the framework of each of the six components of the CCM. 1. Healthcare organisation. We held 18 joint working sessions involving all components of the multidisciplinary team to establish the content of the clinical care and organisational interventions. 2. Delivery system design. A care management model describing the circuits and communications between healthcare and non-healthcare professionals was defined in these joint sessions. 3. Use of clinical informatión systems. We have designed an electronic case history application (PROMIC WEB) shared by all professionals involved in patient care, which acts as a care record, actión reminder and research database. 4. Decision-making support We have standardised the informatión contained in the discharge report and communications between professionals in the return home and protocolised the pharmacological treatments indicated in the pertinent guidelines. The individual problems presented by each patient are managed by way of a comprehensive and personalised intervention. We have designed a theoretical/practical training plan for all study participants 27 hours for physicians and 42 hours for nurses), which has been complemented with a course on electrocardiography, basic recommendations for cardiology and drug titratión for nursing staff. 5. Educatión for the self-care and empowerment of patients and their families. Creation of a new nursing role aimed at coaching and educating patients and their families and evaluating their level of understanding and self-care. We have prepared educational support material for personalised self-care aimed at patients and their carers. 6. Integratión of community resources. We have established meetings and contacts with social workers and community pharmacists.

Project Status: Completed

Year Published: 2014

URL for published report: https://www.euskadi.eus/contenidos/informacion/2014_osteba_publicacion/es_def/adjuntos/pro_Insufcardio.pdf

English language abstract: An English language summary is available

Publication Type: Other

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: Osteba (Basque Office for Health Technology Assessment) Health Department of the Basque Government