Managing patients with chronic diseases is one of the greatest challenges of the 21st century in western European countries. Case management approaches provide an opportunity and option to optimize patients’ self-care, provision of continuous quality care, decreased hospitalization rates, and promotion of cost-effective use of limited and many times insufficient resources. Our Program, called Gestao de Caso, is a case management project in a peripheral Portuguese hospital, serving around 100.000 inhabitants, located in a rural setting of Alentejo Litoral (south Portugal) with distances to the hospital that reach 100 km. It is a people-centered integrated care program, started in January 2017, where Internal Medicine doctors and nurses at the hospital and General Practice doctors and nurses in the community work as an articulated team, enabling a holistic approach. In the community setting, the nurse is the health manager of each patient. The main objectives are: 1) better continuity of care with clinical stabilization and social problems resolution, keeping the patient at home; 2) reduce of healthcare resources utilization. Since we started, we had almost 100 patients enrolled, and currently our program includes 65 chronic complex patients (with more than 6 months in the Program) with a similar gender distribution (51% females; 49% males), with a median age of 76 years (55-88). The median Charlson score is 6.3 and the median Gijon score is 7. Our results account for reductions in the emergency department visits by 61%, hospitalization rates were reduced by 55% and the days of hospitalization were decreased by 58%. Data provided from our office of planning and management support show that these results translate into savings of 167.023 euros for the areas of ambulance transportation, ED visits, and hospital admissions, accounting for savings of 2558 euros per patient/year.
In regard of the community articulation, there are several organizations that we work with in a partnership. Here we talk about three of these organizations, all supported by the city council of Odemira, one of the five counties of Alentejo Litoral.
First, a project called Cui(dar)+, which aim is to support the caregivers and to promote their well-being in a 3-level setting: psychologic, social and physical, offering psychological evaluation and psychotherapy, mutual help groups, social support and caregiver rest period. Currently, 17.5% of our Program’s caregivers are supported by this organization.
Second, Viver Ativo is a program that works against sedentary lifestyle, promoting physical activity for the elderly; 10% of our patients are engaged in this project at the present time.
Third, for those who cannot afford all the medications, there is an economic benefit called ABEM card that provide these patients the prescriptions they need according with their financial status. Five percent of our patients benefit from this support, currently.
Conclusions: All of this teamwork results in a more effective answer for the needs of our patients and caregivers, regarding not only their physical health, but also their psychological well-being and their social and economic needs, altogether in an actual people-centered health system.