A new multidisciplinary unit will attend to chronic patients of high complexity in Lanzarote. This was reported by the Ministry of Health of the Government of the Canary Islands, on which the Management of Health Services of the island depends.
Primary Care professionals and the Geriatrics, Internal Medicine, Palliative Care and Emergency services work in a coordinated manner to respond to the needs of these patients. Chronic patients of high complexity require fully personalized care and present different risk elements such as the limitation of their functional capacity or polypharmacy, among others, which makes a multidisciplinary approach by health professionals essential, according to Sanidad in a note.
In order to respond to chronicity, this team has designed an action protocol with appropriate strategies to deal with its complexity. It is about making a comprehensive assessment of patients by different professionals in order to plan their care and monitoring and jointly assess treatment alternatives and assistance in their different dimensions.
The High Complexity Chronic Patient Care Unit
The protocol establishes a follow-up program to minimize the risk of decompensation and improve the continuity of care, both when the patient is admitted to the hospital from Primary Care, and when he/she is discharged from the hospital and returns home, by the professionals of the health centers.
For this purpose, the High Complexity Chronic Patient Care Unit is expected to guarantee this coordination between Internal Medicine, Geriatrics, Palliative Care and Primary Care and reinforce an intervention plan through the specialists who care for the patients and liaison nursing. This joint work is one of the pillars to guarantee the continuity of care with direct communication between the different levels of care.
"High complexity chronic patients represent between 3-5% of the population, although they usually require more admissions and hospital stays than the rest, so one of the objectives of this action protocol is to guarantee the patient's quality of life and offer maximum accessibility and assistance to caregivers and the family through the coordination of available resources on the island and try to avoid unnecessary trips to the emergency room and reduce the number of hospital admissions," the Ministry points out.
Attention to chronicity Lanzarote
The Primary Care teams of the different basic health areas attend to chronic patients with difficulties to travel to the consultations and for whom the best option is home care, both in Lanzarote and La Graciosa. This task is complemented by the Home Geriatric Care Unit of the Insular Hospital, which in coordination with Primary Care and Liaison Nursing, provide coverage to people who, due to their immobility, isolation, cognitive, behavioral or other reasons, have difficulties accessing the external Geriatrics consultations. This team made a total of 861 home visits during 2022.
The average age of the patients treated is over 75 years and most of them present frailty and advanced dependence, as well as multiple pathologies. The team's interventions focus on socio-health coordination, and for this they hold monthly meetings with social workers, family guidance, the development of individualized care plans and the control of polypharmacy. In addition, the geriatricians of the Unit are the ones who determine the rehabilitation, treatment and prevention of geriatric syndromes.
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For its part, the liaison nursing of Primary Care plays a prominent role in the care of these chronic patients, their families and caregivers to whom it provides quality care and tries to improve their quality of life. Throughout 2022, the team of seven nurses attended a total of 14,972 consultations, of which 1,389 were carried out at home, while the rest were carried out in health centers and through telephone care.
