Every year there are more than 107,000 income Hospitable for heart failure, a chronic disease that prevents the heart from having sufficient capacity to pump blood and that is the first cause of hospitalization in people over 65.
We talk about a disease that affects the quality of life of patients and that, in addition, involves going through intermittent episodes of worsening in which a hospital admission is necessary in most cases. Some data and a reality that make this condition a challenge for the Spanish health system.
Not only because of the income needs of these people. Also because when the discharge arrives, a transition period of great fragility and a crucial moment for the patient is entered, which is when it feels more vulnerable. It is a key time in which it is necessary that a series of requirements be met strictly, such as adherence to treatment, adequate monitoring in which several specialists and education and training of both the patient and their caregiver intervene. It is a time when it is decisive to carry out early monitoring and establish effective coordination between primary and hospital care teams.
Aware of the importance of this post-hospital care, the University Hospital Jiménez Díaz Foundation “That celebrates your.” 90th anniversary– The program implemented in 2023 MAIC Continuum (Assistance models of patient care with heart failure), in coordination and collaboration with primary care, promoted by Boehringer Ingelheim and designed to treat this pathology and minimize the risk of hospital re -entry. After almost two years of journey, the Madrid hospital has been able to register important improvements. As explained by Dr. Oscar Gómez, director of healthcare continuity of the Jiménez Díaz Foundation, “optimize this process minimizes the risk of hospital re -entry and improves the patient’s quality of life.”
Multidisciplinary and continued approach to Hospital Alta
When a person with heart failure is admitted, the objective is triple: “Identify and correct the trigger, decongesting the patient with diuretic treatment; and identify all its comorbidities to optimize its basic treatment and avoid new decompensations, ”says Dr. Alberto Albiñana, specialist at the Internal Medicine Service and the Heart Inadequacy Unit of the Jiménez Díaz Foundation.
But when it is time to receive discharge it is very important to determine, both with the patient and with their relatives and caregivers, how will your follow -up be at home, so that there is a continuity of care. One of the maximum needs is to create a fluid relationship between primary care services and the hospital in order to ensure that healthcare traffic between the two circuits is safe.
In this sense, the MAIC continuum allows a consolidated relationship between these two areas. In the case of the Jiménez Díaz Foundation, this translates into having “a unit of care continuity whose nurse contacts and coordinates with the nurse that will follow the process of that patient in the health center, since before the hospital discharge” , says Dr. Gómez.
The objective is to offer tools that help implement the optimal transition process to hospital discharge from a multidisciplinary approach, in which experts in cardiology, internal medicine, nephrology, an emergency and nursing service are involved.
Getting home does not mean the end of recovery
The ultimate goal of programs such as MAIC continu is to reduce hospital re -entering and also mortality. In the two years of journey that this program carries in the Madrid hospital it has been possible to improve the planning process, the evaluation of the patient’s risk level has been formalized and also the role that each professional assumes in the transition to the discharge. It is also agreed what the necessary pharmacological treatment is and the patient’s movements are included to make an adequate follow -up.
Among the most outstanding digital and communication initiatives in this regard is the econsultation for the heart failure unit, as well as the monitoring of the transition to discharge with indicators since it is necessary that the follow -up during the transition includes an easy access mechanism. All this has allowed 79% of patients to have received early contact at 48-72 hours after hospital discharge, something decisive taking into account that the first seven days after discharge are a period in which the Hospitalization risk It is maximum.
The patients who have been able to have a consultation with the primary care team have also increased from 49% to 75% High weeks.
Another significant fact has been that the rate of patients who have had to re -enter 30 days due to heart failure has gone from 13% to 4%, the same number of patients who have had to visit emergencies for heart failure also at 30 days after discharge. It is estimated that the transition ends when the patient, after a follow -up of at least 30 days, does not present a progression of symptoms or signs of congestion, has the renal function and stable electrolytes and has knowledge in self -care and adherence to the drugs.
Thanks to programs such as this, which has the endorsement of several Spanish societies, such as the Spanish Society of Cardiology (SEC) or the Spanish Society of Internal Medicine (SEMI), among others, the mortality rate after one month has been reduced by 2%.
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