ArticleInternal and emergency medicine2022
Evaluation of a patient-centered integrated care program for individuals with frequent hospital readmissions and multimorbidity.
Article in Internal and emergency medicine, 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 7 papers.
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Who cites it
7 citing papers in PubMed, 16 citations in OpenAlex.
- Precision emergency medicine in health care delivery and access: Framework development and research priorities.Academic emergency medicine : official journal of the Society for Academic Emergency Medicine · 2025Review
- A hospital care coordination team intervention for patients with multimorbidity: A practice-based, participatory pilot study.Chronic illness · 2025Article
- Implementation of hospital-initiated complex interventions for adult people with multiple long-term conditions: a scoping review.BMC health services research · 2025Article
- Models of Integrated Acute Care for Older Adult Inpatients That Incorporate Integrative Health: An Integrative Review.Journal of multidisciplinary healthcare · 2025Review
- Care models for individuals with chronic multimorbidity: lessons for low- and middle-income countries.BMC health services research · 2024Article
- Efficacy of extracting and preventively intervening late-stage older adults who are at high risk for spending high medical costs by using the health check-up system in Japan: a pilot study.Frontiers in public health · 2024Article
- Machine learning and LACE index for predicting 30-day readmissions after heart failure hospitalization in elderly patients.Internal and emergency medicine · 2022Article
Corrections and comments
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Authors and funding
8 authors at 2 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
Managing patients with multimorbidity and frequent hospital readmissions is a challenge. Integrated care programs that consider their needs and allow for personalized care are necessary for their early identification and management. This work aims to describe these patients' clinical characteristics and evaluate a program designed to reducing readmissions. This prospective study analyzed all patients with ≥ 3 admissions to a medical department in the previous year who were included in the Internal Medicine Department chronic care program at the Lucus Augusti University Hospital (Lugo, Spain) between April 1, 2019 and April 30, 2021. A multidimensional assessment, personalized care plan, and proactive follow-up with a case manager nurse were provided via an advanced hospital system. Clinical and demographic variables and data on healthcare system use were analyzed at 6 and 12 months before and after inclusion. Descriptive and survival analyses were performed. One hundred sixty-one patients were included. Program participants were elderly (mean 81.4 (SD 11) years), had multimorbidity (10.2 (3) chronic diseases) and polypharmacy (10.6 (3.5) drugs), frequently used the healthcare system, and were highly complex. Most were included for heart failure. The program led to significant reductions in admissions and emergency department visits (p = .0001). A total of 44.7% patients died within 1 year. The PROFUND Index showed good predictive ability (p = .013), with high values associated with mortality (RR 1.15, p = .001). Patients with frequent hospital readmissions are highly complex and need special care. A personalized integrated care program reduced admissions and allowed for individualized decision-making.
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