General de Villalba values ​​continuity of care

The area of Care Continuity is a key pillar in the Villalba General University Hospital -public hospital Community of Madrid-, which adds value to healthcare, encouraging patients to receive quality, coordinated, complete and continuous medical care in all healthcare settings and institutions involved in their health process, and throughout all its phases.

He Villalba General University Hospitala pioneer in the creation of this area and the figure of its leader more than a decade ago, this strategy seeks to ensure that patients always have the necessary support, building bridges and reinforcing the link, relationship and commitment between Hospital Care, Primary Care, socio-health centers and the social environment, which includes patient associations, schools, town halls and other community environments.

More specifically, this area was born with the objective of working on the coordinated resolution of patient care processes between the two healthcare settings, promoting continuity of care as a means to promote safety and quality in patient care, the efficiency of the system and the satisfaction of users and professionals. To this end, in addition to a medical professional, director of the unit, it has Continuity of Care Nursing professionals, key to coordinating patient care throughout all care trajectories, especially after hospital discharge. Their work guarantees continuous, personalized and quality care, especially for chronic or highly complex patients.

“We want to guarantee person-centered, humane, safe, coordinated and equitable care, accompanying the patient in their journey through the health system and for it to function as a whole, avoiding the fragmentation of care and the patient getting lost or perceiving gaps between the different levels of care, especially in the most complex cases that require continuous monitoring, such as chronic or fragile patients,” explained the doctor. Jesús Fernández Tabera, Director of Care Continuity of General de Villalba. “To achieve this, we encourage professionals to work together, be informed, aligned, communicate and share objectives,” he adds.

Support network

In order to achieve this integration, the hospital has established a joint work system with Primary Care centers and social health centersstrengthening the support network for patients, and delving into areas such as promoting the rational use of medicine; patient safety through surveillance and alert control systems; or the aforementioned attention to chronicity through patient care programs with telemedicine, monographic consultations, nurse case managers in the development of integrated care processes or improvement plans for follow-up after hospital discharge.

On the other hand, Care Continuity works to guarantee patient accessibility to health care with quality and safety criteria by developing protocols with complementary tests in prevalent pathologies referred from Primary Care and using ICT, artificial intelligence or Big Data to encourage high resolution in consultation.

“One of our objectives,” said Dr. Fernández Tabera, “is to create value in the population by implementing new technologies that have contributed to improving the digital transformation in the continuity of care, facilitating better coordination between medical teams, and guaranteeing that information about the patient’s health status is shared effectively and accessible to all parties involved in their care. “The electronic medical record and other improvements and digital tools have allowed us to advance in the early detection of diseases and possible complications, as well as optimize safety and efficiency in the monitoring of patients, avoiding disruptions or inconsistencies in care between the different levels of care,” he added.

Within this framework, they have also been implemented and expanded population health initiatives promoted by the Community of Madridsuch as the early detection programs for breast and colon cancer (DepreCam and PreveColon), and others focused on the early prevention of lung cancer (DepreCap), chronic kidney disease (PreveRenal), cardiovascular risk, childhood obesity or postmenopausal osteoporosis.

Another challenge in this area is improving the patient’s experience in the hospital’s clinical itinerary or trajectory. At this point, work is being done to make it comprehensive and personalized, and to achieve this, tools such as Health Results and Patient Experience (PROMs and PREMs) are used, which allow the patient’s perception to be collected not only about their health results, but also about their experience, making them participate in the design and improvement of care processes through the Patient and Citizen Advisory Council.

Likewise, the hospital also has a plan to improve care for institutionalized patients in social-health centers through the use of video consultation with its professionals through the Social-Health Portal, differential circuits or multidisciplinary care, among other actions.

Health

In addition to comprehensive and continuous patient care, the General University Hospital of Villalba has implemented a Opening Plan to Civil Society aimed at promoting the health, health information and educationto improve the quality of life and, therefore, the general well-being of the community in which they operate through collaboration with external entities such as NGOs, patient associations, educational centers and the media, among other social actors, in addition to Primary Care, socio-health centers and residences.

“Health does not end – nor does it begin – in the hospital. Therefore, we make sure to be present in activities, courses, workshops, schools and other initiatives to raise awareness about self-care and promotion of healthy habits, in collaboration with patient associations, schools and local administrations,” stated the director of Care Continuity of the Villalbino center.

This preventive work extends to the community and educational spherewith activities aimed at addressing key issues for the health of the population, such as mental health education or prevention of sexually transmitted infections, the responsible use of contraceptives and the promotion of healthy lifestyle habits, focusing on risk factors such as tobacco consumption, other addictive behaviors or toxic habits.

It is about “achieving a greater connection with civil society through actions to support the actions of neighborhood associations, patient associations and local administrations; contributing to adequate health education of citizens by promoting training; and making the health professionals of our institution protagonists and social references of good work in the exercise of their profession,” summarized Dr. Jesús Fernández Tabera.

The Care Continuity area of ​​the General University Hospital of Villalba will continue to advance in a model that reinforces coordination between professionals and anticipates the needs of patients. “The strategy involves consolidating an integrated system, capable of responding effectively to clinical and social complexity, and guaranteeing quality, coordinated, complete and continuous care,” he concludes.