chronic disease is in fashion especially in our community autónoma.Sin But patients with chronic diseases have always been a very important part of work health centers.
A special type of patient is called "chronic home." Is a patient, usually old man, who by their socio comorbidity or family (housing, lack of caregivers) have trouble going to the center of salud.A these people are delivering care to domicilio.Desde years in our community special track these Patients with visits nursing programs and social and family assessment.
an important subset of these patients have multiple dependencies and suffer significant income.
efficient health care these patients a major challenge upone services salud.La MBE unit of internal medicine department of Donostia Hospital takes is trying to improve patient care by multingresador organizational changes. Thus arose
addressing the chronic patient care depediente domiciliario.Se formed a working group with all estate management ssocionanitarios involved in primary care, social services, emergency departments and outpatient, hospital at home, admission and representatives of cuidadores.Desde October 2010 to March 2011 have been held weekly meetings to design a multifactorial intervention to improve care for this group.
The initial target population consists of those dependent on chronic street address with> 1 admission during the last Year of Age approximately 105 patients from seven pilot health centers in the region EKIALDE . One of them is our health center Alza
A description is available at this link . And then, see the presentation of the
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