[Sharing and coordinating patient care between the hospital and primary care: some practical proposals]

[Coordination among healthcare levels: systematization of tools and measures]

Improving healthcare coordination is a priority in many healthcare systems, particularly in chronic health problems in which a number of professionals and services intervene. There is an abundance of coordination strategies and mechanisms that should be systematized so that they can be used in the most appropriate context. The present article aims to analyse healthcare coordination and its instruments using the organisational theory. Coordination mechanisms can be classified according to two basic processes used to coordinate activities: programming and feedback. The optimal combination of mechanisms will depend on three factors: the degree to which healthcare activities are differentiated, the volume and type of interdependencies, and the level of uncertainty. Historically, healthcare services have based coordination on skills standardization and, most recently, on processes standardization, through clinical guidelines, maps, and plans. Their utilisation is unsatisfactory in chronic diseases involving intervention by several professionals with reciprocal interdependencies, variability in patients' response to medical interventions, and a large volume of information to be processed. In this case, mechanisms based on feedback, such as working groups, linking professionals and vertical information systems, are more effective. To date, evaluation of healthcare coordination has not been conducted systematically, using structure, process and results indicators. The different strategies and instruments have been applied mainly to long-term care and mental health and one of the challenges to healthcare coordination is to extend and evaluate their use throughout the healthcare continuum.

[Analysis of a programme of direct referral between primary and specialist care in potential surgery patients]

OBJECTIVE

To describe the results of a programme of direct referral of potential surgery patients between primary and specialist care, designed to lessen waiting-times.Design. Prospective, longitudinal and descriptive study.

SETTING

Health Area N. masculine 19 (Valencian Health Service): Surgery Service of Elche Hospital and 6 Health Centres.

PARTICIPANTS

Patients with pathologies that do not need special techniques for diagnosis except examination and who have a clear irrefutable indication of surgery without risk factors (ASA I-II).Intervention. The referral protocol consists of: a) diagnosis of pathology and pre-operative study in primary care (PC); b) appointment made by phone for the surgery clinic at the hospital, where diagnosis and pre-operative study are confirmed; c) referral and operation in the unit of non-hospital major surgery (UCMA); d) monitoring post-operation by the home hospitalisation unit (HHU) or preferably by the health centre, and e) check-up at the surgery clinic. Main measurements. The degree of agreement between PC and the specialist, assessment of the pre-operative study, and waiting time.

RESULTS

86 patients were referred (average age, 35; 76% male) by 28 doctors. The most common pathologies were hernia (36%), pilonidal sinus (23.2%) and miscellaneous (32.5%). There was general agreement in diagnosis in 90.7% of cases. 89.5% of patients brought the proper pre-operative study. Mean waiting time between the primary care consultation in the different procedures and the first hospital consultation was 19 days; with 44 more days elapsing till the surgical operation.

CONCLUSIONS

This new programme is effective and economic, in that there is <<adequate referral>> of patients, waiting time is reduced by over 7 months for pilonidal sinus and by over 2 years for hernia pathology, and the procedure can be used for a large number of patients, as the pathologies involved are very common.