Impact of a high-risk multimorbidity integrated care implemented at the public health system in Chile

Evaluation of patients´ perspective on a multimorbidity patient-centered care model piloted in the chilean public health system

BACKGROUND

The progressive multimorbidity explosion has challenged Chile's health systems and worldwide. The Centro de Innovación en Salud ANCORA UC implemented a new Multimorbidity Patient-Centered Care Model in Chile.

OBJECTIVE

Evaluate the perspective of high-risk patients about the core elements of the model.

METHODOLOGY

We conducted a cross sectional telephone-based survey that considered the application of a 13 items questionnaire. Of them, nine were Likert scale questions with scores from 1 to 7, one dichotomic question, and three open-ended questions. 231 high-risk patients who received care through the model at primary care centers participated in the study. Quantitative data were encoded, consolidated, and analyzed with the SPSS software. We performed descriptive and analytic statistics techniques to assess different variables and their potential associations. Thematic analysis was conducted for qualitative data.

RESULTS

The overall score was 5.84 (range: 1 to 7), with a standard deviation of 1.25. Questions with the best scores were those related with personalized care and the primary care teams. The lowest scored was for the item regarding the continuity of care between primary nurses and inpatient care at the hospital. There was a difference in patient outcomes depending on their health center. Regarding sociodemographic characteristics, age did not significantly affect the results.

CONCLUSIONS

The study reveals the perceptions about a complex multimorbidity intervention from the patient's perspective. It complements the impact on health services utilization evaluation that supports decision-makers currently scaling up a similar strategy in our country and could be considered in other countries dealing with non-communicable diseases.

Evaluation of a Transitional Care Strategy Implemented in Adults With High-Risk and Multimorbidity in Chile

OBJECTIVES

Fragmentation of continuity of care impacts the health system's efficiency and increases inequity. It severely affects high-risk patients with multimorbidity, requiring coordinated care to avoid preventable complications. The Centro de Innovación en Salud ANCORA UC, together with the Servicio de Salud Metropolitano Sur Oriente, and the National Health Fund, implemented a transitional care strategy for high-risk adults with multimorbidity at 3 hospitals in the southeast of Santiago. The study aimed to evaluate the impact on length of hospital stay, consultations with primary care physicians and contacts after discharge, and also to describe the implementation process of the transition nurse activities.

METHODS

A cohort study was performed between 2017 and 2019, with 137 hospitalizations from exposed patients and 167 hospitalizations from unexposed patients. The results of the study showed a significant decrease in the length of hospital stays and an increase in consultations with physicians.

RESULTS

The results of the implementation process showed that the transition nurse followed-up in a mean of 24 hospitalizations monthly, and 91% of the discharged patients were contacted via the telephone within 7 days. The implementation process showed that the transition nurse's tasks merged with the daily clinical activities in which training on case management, transition care, and continuous support were key aspects of success.

CONCLUSION

We conclude that transitional care intervention has a strong potential in addressing fragmentation of care and is feasible to install and sustain over time in the Chilean context. Finally, this study provides a detailed description of the intervention strategy contributing to its spread and scale-up.

Integrating Noncancer Chronic Pain to Multimorbidity: A Real Practice Challenge in Chile

Chronic noncancer pain (CNCP) is, and continues to be, a global problem that affects people with multimorbidity. The objective is to comment on the gap in Chile in integrating multimorbidity and CNCP in the real practice context despite the advances in public policies and local evidence revealed. Therefore, a pilot is responding to this problem by implementing an approach to incorporate into a multimorbidity comprehensive approach the assessment of CNCP and adding nonmedical services. It is expected to evaluate its impact on the performance of the health system, as well as on people.

Economic evaluation of a multimorbidity patient centered care model implemented in the Chilean public health system

Multimorbidity and patient-centered care approaches are growing challenges for health systems and patients. The cost of multimorbidity patients and the transition to a new care strategy is still sightly explored. In Chile, more than 70% of the adult population suffer from multimorbidity, opening an opportunity to implement a Multimorbidity patient-centered care model. The objective of this study was to perform an economic evaluation of the model from the public health system perspective.The methodology used a cost-consequence evaluation comparing seven exposed with seven unexposed primary care centers, and their reference hospitals. It followed three steps. First, we performed a Time-Driven Activity-Based Costing with routinely collected data routinely collected. Second, we run a comparative analysis through a propensity score matching and an estimation of the attributable costs to health services utilization at primary, secondary and tertiary care and health outcomes. Third, we estimated implementation and transaction costs.Results showed savings in aggregate costs of the total population (-0.12 (0.03) p < 0.01) during the period under evaluation. Costs in primary care showed a significant increase, whereas tertiary care showed significant savings. Health outcomes were associated with higher survival in patients under the new care model (HR 0.70 (0.05) p < 0.01). Implementation and transaction costs increased as the number of pilot intervention centers increased, and they represented 0,07% of the total annual budget of the Servicio de Salud Metropolitano Sur Oriente. After three years of piloting, the implementation and transaction cost for the total period was USD 1,838,767 and 393,775, respectively.The study's findings confirm the purpose of the new model to place primary health care at the center of care for people with non-communicable chronic diseases. Thus, it is necessary to consider implementation and transaction costs to introduce a broad health system multimorbidity approach. The health system should assume some of them permanently to guarantee sustainability and facilitate scale-up.

Advancing towards the implementation of patient-centred care in Chile: An opportunity to effectively practice shared decision-making

In Chile, local normative and guidelines place patient-centred care (PCC) as a desirable means and outcome for each level of health care. Thus, a definition of PCC is provided, and for the first time shared decision-making (SDM) is included as an intended practice. During the past five years the country has shown progress on the implementation of PCC. A large pilot study was conducted in one of the Metropolitan Health Services, and now the health authority is committed to escalate a PCC strategy nationwide. From the practice domain, most of the work is being placed on the training of health professionals. Patients' preparation for the clinical encounter is scarce, thereby limiting their potential to participate in their care. At the research domain, the country shows a strengthened agenda that has advanced from a diagnostic phase (including the exploration from social sciences) to a purposeful stage which involves the development of training programs, patient decision aids, international collaborations, and other PCC interventions. The country is now positioned to secure new initiatives to empower patients and allow them to take an active role, as a key component of PCC and SDM.

Effect of COVID-19 pandemic on the implementation of a multimorbidity person-centered care model: A qualitative study from health teams’ perspective

The COVID-19 pandemic has abruptly changed care priority and delivery, delaying others like the multimorbidity approach. The Centro de Innovación en Salud ANCORA UC, the Health National Fund, and the Servicio de Salud Metropolitano Sur Oriente implemented a Multimorbidity Patient-Centered Care Model as a pilot study in the public health network from 2017 to 2020. Its objective was to reorganize the single diagnosis standard care into a new one based on multimorbidity integrated care. It included incorporating new roles, services, and activities according to each patient’s risk stratification. This study aims to describe the perception of the health care teams regarding the impact of the COVID-19 pandemic on four main topics: how the COVID-19 pandemic affected the MCPM implementation, how participants adapted it, lessons learned, and recommendations for sustainability. We conducted a qualitative study with 35 semi-structured interviews between October and December 2020. Data analysis was codified, triangulated, and consolidated using MAXQDA 2020. Results showed that the pandemic paused the total of the implementation practically. Positive effects were the improvement of remote health care services, the activation of self-management, and the cohesion of the teamwork. In contrast, frequent abrupt changes and reorganization forced by pandemic evolution were negative effects. This study revealed the magnitude of the pandemic in the cancelation of health services and identified the urgent need to restart chronic services incorporating patient-centered care in our system.