Characteristics and Service Utilization by Complex Chronic and Advanced Chronic Patients in Catalonia: A Retrospective Seven-Year Cohort-Based Study of an Implemented Chronic Care Program

Sebastià J. Santaeugènia, Joan C. Contel, Emili Vela, Montserrat Cleries, Paloma Amil, Eva M. Melendo-Azuela, Esther Gil-Sánchez, Victoria Mir and Jordi Amblàs-Novellas
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Sebastià J. Santaeugènia: Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic—Central University of Catalonia (UVIC-UCC), 08500 Barcelona, Spain
Joan C. Contel: Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic—Central University of Catalonia (UVIC-UCC), 08500 Barcelona, Spain
Emili Vela: Unitat d’Informació i Coneixement, Servei Català de la Salut, 08006 Barcelona, Spain
Montserrat Cleries: Unitat d’Informació i Coneixement, Servei Català de la Salut, 08006 Barcelona, Spain
Paloma Amil: Chronic Care Program, Department of Health, Generalitat de Catalunya, 08020 Barcelona, Spain
Eva M. Melendo-Azuela: Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic—Central University of Catalonia (UVIC-UCC), 08500 Barcelona, Spain
Esther Gil-Sánchez: Chronic Care Program, Department of Health, Generalitat de Catalunya, 08020 Barcelona, Spain
Victoria Mir: Chronic Care Program, Department of Health, Generalitat de Catalunya, 08020 Barcelona, Spain
Jordi Amblàs-Novellas: Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic—Central University of Catalonia (UVIC-UCC), 08500 Barcelona, Spain

IJERPH, 2021, vol. 18, issue 18, 1-20

Abstract: The Chronic Care Program introduced in Catalonia in 2011 focuses on improving the identification and management of complex chronic (CCPs) and advanced chronic patients (ACPs) by implementing an individualized care model. Its first stage is their identification based on chronicity, difficult clinical management (i.e., complexity), and, in ACPs, limited life prognosis. Subsequent stages are individual evaluation and implementation of a shared personalized care plan. This retrospective study, including all CCPs and ACPs identified in Catalonia between 2013 and 2019, was aimed at describing the characteristics and healthcare service utilization among these patients. Data were obtained from an administrative database and included sociodemographic, clinical, and service utilization variables and morbidity-associated risk according to the Adjusted Morbidity Groups (GMA) stratification. During the study period, CCPs’ and ACPs’ prevalence increased and was higher in lower-income populations; most cases were women. CCPs and ACPs had all comorbidities at higher frequencies, higher utilization of healthcare services, and were more frequently at high risk (63% and 71%, respectively) than age-, sex-, and income level-adjusted non-CCP (23%) and non-ACP populations (30%). These results show effective identification of the program’s target population and demonstrate that CCPs and ACPs have a higher burden of multimorbidity and healthcare needs.

Keywords: chronic care; integrated care; geriatric care; palliative care; primary health care; multimorbidity; complexity; healthcare services utilization; complex needs; advanced chronic patients (search for similar items in EconPapers)
JEL-codes: I I1 I3 Q Q5 (search for similar items in EconPapers)
Date: 2021
References: View references in EconPapers View complete reference list from CitEc
Citations: View citations in EconPapers (3)

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