Dossier n. 236/2013 [Abstract] Multidimensional assessment of paths of continuity of care. Territorial management applying the chronic care model

The primary objective of the project “Management of high territorial impact chronic diseases according to the chronic care model, in order to reduce disability, the inappropriate use of hospitalization, and to improve patients’ and caregivers’ quality of life” is to assess the outcomes of an experimental health care model based on the chronic care model, and aimed at patients treated for a femur fracture or a stroke. The CCM is a health care model for chronic diseases that proposes a series of changes in order to improve patients’ conditions, introducing a proactive approach between health care workers and patients themselves, who become an integral part in the process. The model has six basic domains: community resources, health care organization, patient self-management support, delivery system redesign, decision support, and clinical information support.

This study assessed the impact of a chronic care model implementation in terms of clinical and functional outcomes, changes in patients’ perceived quality of life and psychosocial vulnerability. The impact was monitored using a multidimensional assessment tool previously tested in the 2008/2009 project titled “Multidimensional assessment of elderly patients: Applying tools to evaluate continuity of care” (Palestini et al., 2012). The study design is quasi-experimental, including a pre- vs. post-treatment comparison between an experimental and a control group. The experimental condition is based on the introduction of chronic care elements in health care services, while in the control condition there is not any change in terms of chronic care.

The study involved 350 participants, recruited from the Health Trusts in Bologna e Ferrara. We first carried out a cross-sectional assessment - in order to pinpoint a baseline in clinical and functional status and perceived quality of life - and then a 1-month follow up assessment. After introducing the experimental chronic care elements, we carried out a 6-month follow-up assessment in order to evaluate any longitudinal changes in patients’ clinical and functional outcomes and perceived quality of life within each group, as well as to compare the two groups.

Results show that the multidimensional assessment tool provides consistent and informative data on patients’ outcomes and status. Patients’ basic and instrumental functionality deteriorates 1 month after entering the health care services and is significantly recovered 6 months later, even though it never returns to the previous level; perceived pain decreases 1 month after patients are recruited and does not undergo further changes; perceived quality of life does not show ant change 1 month after the first assessment, while it significantly increases 6 months later. The chronic care elements, which were introduced to enhance patient self-management support and to intercept patients’ needs, did not seem to affect the results, so they may not be able to cause a further improvement in patients’ conditions.

However, we observed a moderation effect caused by age and pathology of the participants. Patients aged more than 80 years show significantly worse clinical and functional levels when compared to other participants; moreover, the perceived quality of life shows a reversal in its previously detected pattern and significantly decreases over a 6 months period from patients’ first hospital admission.

Patients suffering from a fractured femur show a lower functional status than those who have suffered a stroke after their recruitment, but these differences disappear at the 6-month follow-up. Perceived pain is moderated by patients’ pathology, as participants suffering from a fractured femur show a very high pain level when admitted in hospitals, but this level significantly decreases one month later.

In addition, the improvement in perceived quality of life appears as a common element in both pathologies, and it occurs over the 6-month period - when patients have already left the health care facilities they were initially admitted in.