TY - JOUR
AU - M. Barneto-Soto
AU - N. Molist-Brunet
AU - E. Puigoriol-Juvanteny
AU - A. R. Nadal
AU - R. M. T. Allepuz
AU - J. Espaulella-Panicot
A1 - 
AB - INTRODUCTION: Person centred care planning and models of care coordination across levels of care reduce fragmentation and unnecessary resource use. Our objectives were to assess the impact of implementing a coordinated care model between intermediate care and primary care, as determined by the identification of complex patients, and recording their individualized care plans in the shared medical record and to assess its effectiveness in relation to the use of health resources. METHODS: A pre-post quasi-experimental study of 160 complex patients with dementia who were discharged from intermediate care between April 2022 and July 2024. RESULTS: A 31.4% (from 63 to 106 patients) increase in the identification of complex patients with dementia and a 23.6% (from 19 to 44 patients) increase in the development of care plans were found at 3 months of discharge. Of the patients who had visited emergency department in the six months preceding hospitalisation, 54.4% (n = 31) did not visit it in the six months post-discharge (p = 0.026). CONCLUSION: Our coordinated care model may have contributed to improved identification of patients with dementia and complex conditions, the development of individualized care plans, and reduced emergency department use.
AD - Territorial Service of Geriatrics and Palliative Care from Osona and Ripollès, Fundació Hospital Universitari de la Santa Creu-Consorci Hospitalari Vic, Hospital de Campdevànol, Catalonia, Spain.; Central Catalonia Chronicity Research Group (C3RG), Institut de Recerca i Innovació en Ciències de la Vida i de la Salut de la Catalunya Central (IRIS-CC), 08500 Vic, Catalonia, Spain.; Parc Sanitari Pere Virgili, Barcelona, Catalunya, Spain.; Universitat de Vic-Universitat Central de Catalunya (UVic-UCC), Spain.; RE-FIT Barcelona Research Group, Vall d'Hebron Institute of Research (VHIR), Catalunya, Spain.; Universitat Autònoma de Barcelona, Barcelona, Catalunya, Spain.; Consorci Hospitalari Vic, Catalonia, Spain.; Multidisciplinary Inflamation Research Group (MIRG), Institut de Recerca i Innovacióe n, Ciències de la Vida i de la Salut a la Catalunya Central (IRIS-CC), 08500 Vic, Catalonia, Spain.
AN - 42221425
BT - Int J Integr Care
C5 - Education & Workforce; Healthcare Disparities
CP - 2
DA - 12/1969
DO - 10.5334/ijic.10026
DP - NLM
ET - 20260526
IS - 2
JF - Int J Integr Care
LA - eng
N2 - INTRODUCTION: Person centred care planning and models of care coordination across levels of care reduce fragmentation and unnecessary resource use. Our objectives were to assess the impact of implementing a coordinated care model between intermediate care and primary care, as determined by the identification of complex patients, and recording their individualized care plans in the shared medical record and to assess its effectiveness in relation to the use of health resources. METHODS: A pre-post quasi-experimental study of 160 complex patients with dementia who were discharged from intermediate care between April 2022 and July 2024. RESULTS: A 31.4% (from 63 to 106 patients) increase in the identification of complex patients with dementia and a 23.6% (from 19 to 44 patients) increase in the development of care plans were found at 3 months of discharge. Of the patients who had visited emergency department in the six months preceding hospitalisation, 54.4% (n = 31) did not visit it in the six months post-discharge (p = 0.026). CONCLUSION: Our coordinated care model may have contributed to improved identification of patients with dementia and complex conditions, the development of individualized care plans, and reduced emergency department use.
PY - 2026
SN - 1568-4156 (Print)
SP - 15
ST - Evaluation of the Impact of a Coordinated Intervention Model for Complex Older Patients with Dementia
T1 - Evaluation of the Impact of a Coordinated Intervention Model for Complex Older Patients with Dementia
T2 - Int J Integr Care
TI - Evaluation of the Impact of a Coordinated Intervention Model for Complex Older Patients with Dementia
U1 - Education & Workforce; Healthcare Disparities
U3 - 10.5334/ijic.10026
VL - 26
VO - 1568-4156 (Print)
Y1 - 2026
ER -