Challenges and improvement strategies in the hospitalization of chronic multimorbid patients

Abstract

BACKGROUND

Addressing the growing challenge of hospitalizing chronic multimorbid patients, this study examines the strain these conditions impose on healthcare systems at a local level, focusing on a pilot program. Chronic diseases and complex patients require comprehensive management strategies to reduce healthcare burdens and improve patient outcomes. If proven effective, this pilot model has the potential to be replicated in other healthcare settings to enhance the management of chronic multimorbid patients.

AIM

To evaluate the effectiveness of the high complexity unit (HCU) in managing chronic multimorbid patients through a multidisciplinary care model and to compare it with standard hospital care.

METHODS

The study employed a descriptive longitudinal approach, analyzing data from the Basic Minimum Data Set (BMDS) to compare hospitalization variables among the HCU, the Internal Medicine Service, and other services at Antequera Hospital throughout 2022. The HCU, designed for patients with complex chronic conditions, integrates a patient-centered model emphasizing multidisciplinary care and continuity post-discharge.

RESULTS

The study employed a descriptive longitudinal approach, analyzing data from the BMDS to compare hospitalization variables among the HCU, the Internal Medicine Service, and other services at Antequera Hospital throughout 2022. The HCU, designed for patients with complex chronic conditions, integrates a patient-centered model emphasizing multidisciplinary care and continuity post-discharge.

CONCLUSION

This study demonstrates the effectiveness of the HCU in managing patients with complex chronic diseases through a multidisciplinary approach. The coordinated care provided by the HCU results in improved patient outcomes, reduced unnecessary hospitalizations, and better management of patient complexity. The superiority of the HCU compared to standard care is evident in key outcomes such as fewer readmissions and higher patient satisfaction, reinforcing its value as a model of care to be replicated.

Key Words: High complexity unit; Chronic multimorbidity; Patient-centered care; Integrated care; Healthcare management

Core Tip: This observational study examines the effectiveness of a multidisciplinary care model implemented in the high complexity unit (HCU) for patients with chronic multimorbidity. The HCU model, through personalized and integrated care, significantly reduces unnecessary hospitalizations and improves patient outcomes. The study also highlights how this approach ensures better management of complex chronic conditions compared to standard hospital care, making it a model worth replicating in other healthcare settings.

INTRODUCTION

Chronic diseases represent one of the most pressing challenges for healthcare systems worldwide[1]. These prolonged and often debilitating health conditions, which include, but are not limited to, diabetes, hypertension, chronic obstructive pulmonary disease, heart failure, chronic kidney disease, arthritis, dementia, and chronic liver disease, affect millions of people around the globe. As the population ages and lifestyle-related risk factors continue to rise, the healthcare of chronic diseases has become a topic of utmost relevance in the medical and public health community[2].

Complex chronic diseases pose a significant burden on healthcare systems worldwide. These health conditions, which often involve multiple chronic diseases and comorbidities, contribute considerably to hospitalizations and healthcare costs[3]. Comorbidity refers to the coexistence of two or more chronic diseases or conditions in a patient at the same time. A chronic complex patient is someone who not only has multiple chronic diseases but also faces a higher burden of care due to the complexity of managing these conditions simultaneously, often requiring a coordinated, multidisciplinary approach. While chronic diseases are primary conditions, comorbidities arise when additional diseases complicate the management of the primary condition, leading to increased healthcare costs and more frequent hospitalizations[4].

Among the difficulties that must be faced in the clinical management of these patients is comorbidity, which often requires complex management of pharmacological treatment, increasing the risk of drug interactions and side effects. Additionally, fragmented care among different specialists and the lack of coordination among care providers can lead to unnecessary hospitalizations. Likewise, social, economic, and lifestyle factors play a crucial role in the health of patients with chronic diseases, and their inadequate addressal can increase hospitalizations[5,6].

Any strategy focused on the approach to the chronic patient must start from a patient-centered approach, involving the patient in decision-making and promoting education on self-care and implementing coordinated care systems that connect different health professionals and ensure an effective flow of information[7,8].

Analyzed strategy: High complexity unit

The high complexity unit (HCU) specialized in patients with complex chronic diseases and intensive care situations focuses on providing comprehensive and personalized care. The main goal is to prevent the hospitalization of these patients, who are often over 80 years old, due to the adverse effects it can have on their underlying disease. The unit differs from others in the hospital in terms of staff-to-patient ratios, individual rooms, multidisciplinary coordination, and patient-centered and caregiver-centered care. The importance of transition to discharge and continuity of care with primary care is emphasized. A detailed multidimensional evaluation of the unit is monitored, and specific measures for caregivers and fragile patients are mentioned, including workshops, discharge planning, and resource management. The aim is to improve the experience of patients and their caregivers during their stay in the unit and to reduce the care burden on nursing staff, as well as patient readmissions[9].

Efficient management of complex chronic patients represents a significant challenge for contemporary health systems, given their high demand for resources and the need for optimal care coordination. The HCU stands as a comprehensive solution to this problem, offering a specialized care model that prioritizes the personalization of treatment and continuity of care. This article aims to describe the admission procedure of the complex chronic patient to the HCU, emphasizing the importance of a multidisciplinary and stratified approach to optimize clinical outcomes and patient satisfaction.

MATERIALS AND METHODS

A descriptive longitudinal study was conducted to analyze and compare variables related to hospitalizations between the HCU, the Internal Medicine Service, and other services of the Antequera Hospital throughout the year 2022. For this purpose, information from the Basic Minimum Data Set (BMDS), corresponding to the hospital activity of that period, was used.

The BMDS is a hospital information system that collects, stores, and processes data related to hospital discharges. This system is widely used in various countries, including Spain, and its main purpose is to facilitate healthcare management, planning, and the evaluation of the quality and efficiency of health services. Through the BMDS, standardized data on hospitalized patients are collected, including demographic information, diagnoses, procedures performed during the hospital stay, admission regime, type of discharge, and length of stay, among other aspects[9]. The data collected in the BMDS are fundamental for epidemiological and clinical analysis, allowing studies on disease prevalence, use of medical procedures, analysis of quality and safety of care, public health research, and planning and resource allocation. Additionally, this dataset supports evidence-based decision-making for health policies and improvement strategies in patient care[10].

Statistical analysis

The HCU, integrated within the Clinical Management Unit of Internal Medicine, was subject to a detailed analysis; separating and comparing its discharge episodes with those of the general Internal Medicine service. Data were categorized according to Diagnosis-Related Group (DRG) using the APR-DRG version 36 standard to ensure a standardized comparison[11].

Admission process in the HCU

The admission procedure in the HCU begins in the emergency service with a preliminary evaluation through the triage consultation. During this initial phase, the nursing team records both the patient's reason for consultation and their score on the Antequera Fragility Scale (EPADI)[12], a validated instrument designed to stratify the patient's complexity based on variables such as age, cognitive impairment (measured by the Pfeiffer test), level of dependence (evaluated by the Barthel index), associated comorbidity (abbreviated Charlson index), socio-family assessment (Gijón scale), and the presence of multimorbidities. According to the results obtained on the EPADI scale, patients are classified into one of four levels of complexity: (1) Non-complex; (2) Low complexity; (3) Medium complexity; and (4) High complexity. This assessment is performed under the patient's baseline situation by primary care professionals. This classification guides subsequent clinical decisions regarding the management and possible admission of the patient to the UAC.

Next, the need for admission is assessed by the responsible physician, considering the EPADI score among other significant clinical factors. Patients with an EPADI score of 6 or greater were considered eligible for admission to the HCU. However, in cases where the EPADI score was below 6, the complexity of the patient’s condition and their level of frailty could still be assessed by the medical and nursing team. In such instances, a holistic evaluation of the patient’s overall clinical situation was conducted, and the decision to admit them to the HCU could be made based on clinical judgment, particularly if the patient exhibited significant fragility or required intensive, multidisciplinary care. The multidisciplinary management plan implemented in the HCU involves a comprehensive and coordinated approach to patient care. Upon admission, patients undergo an initial medical evaluation conducted by the internal medicine team. This is followed by a therapeutic reconciliation coordinated through the pharmacy service, ensuring the proper management of medications, reviewing pre-existing prescriptions, and adjusting them to avoid interactions and optimize treatment outcomes. The rehabilitation medicine team evaluates the patient’s physical condition and designs a tailored rehabilitation program, which may include physical therapy sessions aimed at improving mobility and reducing the risk of future hospitalizations. A case manager nurse plays a pivotal role, coordinating all aspects of the patient’s care, including daily communication between the different specialists involved, such as nutritionists, physiotherapists, and palliative care teams, ensuring a cohesive treatment plan is in place. Furthermore, prior to discharge, the case manager nurse, in collaboration with the primary care team, organizes a detailed discharge plan that includes follow-up appointments, home care instructions, and referrals to outpatient services where necessary. Social workers are involved in assessing the socio-familial situation of the patient, ensuring that any social or economic barriers to effective care are addressed, such as arranging for home health aides or providing access to community resources. This coordinated discharge planning ensures that the patient transitions smoothly from hospital to home, reducing the likelihood of readmissions and ensuring continuity of care.

However, for patients with an EPADI score of less than 6, the standard hospital care model was applied. In these cases, the patient was admitted to the appropriate service based on the primary pathology that prompted the hospitalization, following the traditional model of care. This typically involved the patient being managed by the primary specialty responsible for their condition, with additional consultations from other specialties as needed. For example, if a patient was admitted due to heart failure, the cardiology service would lead their care, with interconsultations from other relevant specialties such as neumology or traumatology, depending on the patient's comorbidities.

RESULTS

During the year 2022, the HCU recorded a total of 387 admissions, with a gender distribution of 183 women and 204 men. This section details the activity indicators extracted from the BMDS, comparing the UAC as a whole with the Internal Medicine Service and the Hospital de Antequera (Table 1).

Table 1 Comparison of management indicators of high complexity unit vs internal medicine service vs hospital.

Management indicators	High complexity unit	Internal medicine service	Hospital
Cleared discharges	368	1764	5597
Net average length of stay	8.99	9.49	5.79
Adjusted length of stay by case mix	7.86	8.39	5.62
Adjusted length of stay by operation	8.15	7.47	5.36
Adjusted mean length of stay	1.10	1.27	1.08
Case index	1.19	1.16	1.05
Functional index	1.15	1.30	1.10
Impact (avoidable stays)	310.56	3568.6	2412.07

Key activity indicators

Gross discharges: The UAC accounted for 387 discharges, in contrast to the 1929 discharges from the Internal Medicine Service and the 5914 from the Hospital de Antequera, highlighting the UAC's specific focus on highly complex patients.

Average length of stay: The average length of stay was 10.3 days in the HCU, slightly less than the 10.93 days recorded in Internal Medicine, and significantly higher than the hospital's average of 6.7 days. This data highlights the intensive care required by the UAC patients.

Average age of patients: The UAC had an average patient age of 82.95 years, higher than the 67.93 years of Internal Medicine and the 56.33 years for the hospital overall, indicating a higher proportion of elderly population in the UAC.

Average diagnoses: Patients in the UAC had an average of 13.72 diagnoses each, exceeding the 10.47 of Internal Medicine and the 7.51 of the hospital, evidencing the complexity and multipathology of the cases managed in the UAC.

Average procedures: The average of 1.89 procedures per patient in the HCU was lower than the 2.78 reported in Internal Medicine and the 2.39 in the hospital, reflecting a more strategic and patient-centered selection of interventions.

Average case weight: With an average case weight of 0.89, the HCU showed a higher care load than the 0.83 of Internal Medicine and the 0.76 overall hospital, underscoring the greater intensity of resources devoted to each patient.

Comparative evaluation

Cleared discharges and net average length of stay: The HCU presented 368 cleared discharges with a net average length of stay of 8.99 days, compared to the 9.49 days of Internal Medicine and the 5.79 days in the hospital, reflecting optimized management of hospital stays.

Efficiency indices: The HCU demonstrated average length of stay adjusted for case mix of 7.86 and for operation of 8.15, indicative of efficient management adapted to the complexity of its patients.

Adjusted average length of stay, case and functional indices: With adjusted average length of stay (AALS) values of 1.10, case index of 1.19, and functional index of 1.15, the HCU stands out for its efficiency and complexity in care, comparatively superior to both the Internal Medicine Service and the hospital in general.

Impact on the reduction of unnecessary hospital stays

The analysis highlights the HCU's notable success in reducing avoidable hospital stays, with 310.56 days, in stark contrast to the 3568.6 days of the Internal Medicine Service. This achievement emphasizes the HCU's effectiveness in preventing unnecessary admissions and efficiently managing patients with complex chronic conditions.

Patient experience

In the framework of the comprehensive project evaluation, a data collection protocol was implemented that included semi-structured interviews and surveys directed at both patients and their relatives, aiming to elucidate the patient experience and assess the effectiveness of the provided care services. A total of 170 interviews were conducted, structured around a set of 22 items, whose responses were recorded using a five-point likert scale, ranging from 1 ("very poor") to 5 ("very good"). This methodology allowed quantifying the respondents' perception in terms of overall satisfaction with the service received.

Statistical analyses were conducted to examine the distribution of responses based on demographic variables and their relationship to the service (gender, age, and whether the individual was a patient or a companion), using appropriate contrast tests. The results of these analyses did not reveal statistically significant differences among the compared groups, suggesting that the perception of the quality of care is uniformly high regardless of these variables. The in-depth interviews provided additional narratives about the specific elements of care that contribute to a positive patient experience, detailing aspects of both personal interaction and the care environment (Figure 1). These findings underscore the importance of considering a variety of factors in evaluating the quality of healthcare services.

Figure 1  Word cloud from in-depth interviews with patients and caregivers.

DISCUSSION

This study provides a comprehensive analysis of the inherent challenges in the hospitalization of patients with complex chronic diseases, highlighting the difficulties faced by both patients and healthcare systems. Focusing on critical challenges, specific strategies are outlined to optimize care and minimize unnecessary hospital admissions. The management of patients with multiple comorbidities and under polypharmacy highlights the risks of adverse drug interactions and side effects, emphasizing the importance of coordinated care and the mitigation of these risks[13,14].

The lack of coordination in medical care emerges as a significant contributor to unplanned hospitalizations, underlining the need for an integrated strategy that addresses social determinants and lifestyle factors affecting the health of these patients. The proposed solutions to improve healthcare are both practical and outcome-oriented, emphasizing the centrality of the patient in the decision-making process and promoting a culture of self-care and education[15,16].

Despite the valuable findings and contributions of this study, it's important to recognize as a potential limitation that could influence the interpretation and generalization of the results the longitudinal descriptive design of the study, which, although robust for assessing trends and changes over time, does not allow for establishing causal relationships between the interventions carried out in the HCU and the observed outcomes.

The HCU is examined in detail, demonstrating how the implementation of these strategies can be realized in practice. The HCU is recognized for its comprehensive and personalized approach to care, placing special emphasis on the transition to discharge and ensuring effective continuity of care. The adoption of a case management model to facilitate collaboration between primary and hospital care is key for a successful interdisciplinary care strategy[17-20].

The data obtained from the BMDS for the year 2022 provide a detailed evaluation of the HCU's performance, using key indicators to compare it with the Internal Medicine Service and the hospital as a whole. The findings reveal a notable difference in the management and outcomes of the HCU, highlighting superior effectiveness in the care of patients with complex medical conditions. The comparison of indicators such as the gross average length of stay, the average age of the patients, the average number of diagnoses and procedures, and the average case weight underscores the greater workload and complexity of the cases managed by the HCU.

Furthermore, indices such as the AALS, case index, and functional index offer a deeper perspective on the efficiency and complexity of the care provided by the HCU compared to other units. These indices confirm the HCU's efficiency in managing stays, despite treating patients of greater complexity. Finally, the analysis of avoidable stays underscores the HCU's ability to significantly reduce hospitalization days, consolidating its fundamental role in improving the quality of care and reducing the impact on hospital resources and patient well-being. This study also emphasizes the importance of a comprehensive evaluation of the patient experience, highlighting that both quantitative and qualitative indicators are crucial for understanding and improving the quality of healthcare services.

CONCLUSION

This study demonstrates the effectiveness of the HCU in managing patients with complex chronic diseases, through a multidisciplinary approach. The coordinated care provided by the HCU results in improved patient outcomes, reduced unnecessary hospitalizations, and better management of patient complexity. The superiority of the HCU compared to standard care is evident in key outcomes such as fewer readmissions and higher patient satisfaction, reinforcing its value as a model of care to be replicated.