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

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dc.contributor.authorVarela, Teresita
dc.contributor.authorZamorano, Paula
dc.contributor.authorMunoz, Paulina
dc.contributor.authorEspinoza, Manuel
dc.contributor.authorTellez, Alvaro
dc.contributor.authorIrazoqui, Esteban
dc.contributor.authorSuarez, Francisco
dc.date.accessioned2025-01-20T20:06:03Z
dc.date.available2025-01-20T20:06:03Z
dc.date.issued2023
dc.description.abstractObjectives: 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 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.
dc.fuente.origenWOS
dc.identifier.doi10.1016/j.vhri.2023.07.003
dc.identifier.issn2212-1099
dc.identifier.urihttps://doi.org/10.1016/j.vhri.2023.07.003
dc.identifier.urihttps://repositorio.uc.cl/handle/11534/91724
dc.identifier.wosidWOS:001066451000001
dc.language.isoen
dc.pagina.final92
dc.pagina.inicio85
dc.revistaValue in health regional issues
dc.rightsacceso restringido
dc.subjectcontinuity of care
dc.subjecthospitalization
dc.subjectimpact evaluation
dc.subjectmultimorbidity
dc.subjecttransition care.
dc.subject.ods03 Good Health and Well-being
dc.subject.odspa03 Salud y bienestar
dc.titleEvaluation of a Transitional Care Strategy Implemented in Adults With High-Risk and Multimorbidity in Chile
dc.typeartículo
dc.volumen38
sipa.indexWOS
sipa.trazabilidadWOS;2025-01-12
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