Jordi Varela, Editor of the blog “Advances in Clinical Management“
It is said that the best savings in health is in avoidable hospitalisation that doesn’t occur, especially since the use of a hospital bed is the most expensive health resource of all the health offers, but also because if one person, let’s imagine an elderly one with several chronic conditions, can avoid being admitted in hospital, his/her health will suffer less compromising situations. For this reason, all health systems are very active in trying to launch all kinds of measures to reduce the admission of chronic and frail patients.
See below what actions have been proven to reduce unnecessary hospitalisations (for the source of evidence, consult the King’s Fund paper):
1. Continuing care offered by the family doctor. There is evidence that avoidable admissions occur with greater intensity after working hours (nights and weekends) when the usual primary care service is unavailable.
2. Home hospitalization as an alternative to hospital admission. These programs have shown that if the choice of patients is a good fit, the results are comparable to those of hospital admission, albeit at a somewhat lower or similar cost.
3. Case management specifically geared to mental health. Multidisciplinary action programs in the community are effective, especially if they focus on patients with repeated admissions.
4. Self-care promotion. It seems that if chronic patients understand how their illness affects them and how they should cope with the symptoms that affect them, their dependence on specialised hospital care is reduced. According to experts, the key to success lies in the development of individual action plans.
5. The presence of senior medical staff in the hospitals’ emergency departments. The cited studies show that, to be effective, these doctors (already trained) should review at an early stage those cases arriving at the emergency department not having been sent by a family doctor.
6. Multidisciplinary interventions and remote monitoring for patients with heart problems. The most effective interventions are those that combine monitoring of vital signs with telephone follow-up by nurses, actions that should be part of a personalised plan with the support of specialised equipment.
7. The integration of primary care and specialised care. For this action to be effective, the integration must be effective too i.e. simply moving specialists from hospitals to health centres is not effective.
There are three other actions that have shown little or no evidence of effectiveness in reducing hospitalisations:
- Pharmacist at home to check the understanding and the adherence to the medication.
- Intermediate care: hospitalisation units run by nurses.
- Case management within the community (except mental health).
To end this review, I would like to share a small excerpt from the conclusions of a report from the American Robert Wood Johnson Foundation on the drawing near to the community of patients with complex health needs.
“(…) One of the success factors of Care Management is the patients’ choice. CMs programs of intensive performance that group high-risk patients at a single point of performance are very promising. Such programs can be liberating for primary care, in the sense that there would be a small number of highly needy patients that would stop distracting them from their usual work.”
- Purdy S. Avoiding hospital admisiones. What does the research evidence say? The King’s Fund. December 2010. Se puede bajar libremente de internet.
- Kane RL, Keckhafer G, Flood S, Bershadsky B, Siadaty MS. The Effect of Evercare on Hospital Use. JAGS 2003; 51:1427-34.
- Díaz-Gegúndez M, Paluzie G, Sanz-Ballester C, Boada-Mejorana M, Terré-Ohme S, Ruiz-Poza D. Evaluación de un programa de intervenciones en residencias geriátricas para reducir la frecuentación hospitalaria. Rev Esp Geriatr Gerontol. 2011; 46:261-4.
- Gravelle H, Dusheiko M, Sheaffer R, Sargent P, Boada R, Pickard S, Parker S, Roland M. Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data. BMJ 2007; 334:31-4.
- Bodenheimer T, Berry-Millett R. Care Management of patients with complex health care needs. The Synthesis project. Robert Wood Johnson Foundation. December 2009. Se puede descargar libremente.