[Case management as a methodology for connecting the health and social care systems in Spain]

The aim of this paper is to present the assessment of a case management project, implemented with chronic patients in Valencia, for the integration of health and social care. This project is linked with the 'Sustainable Socio-Health Model'.

Health department 06 in Valencia.

The target groups were chronic patients of 65 years and over.

A non-randomized non-blinded comparative study with an intervention and control group. The intervention consisted in the creation of an interdisciplinary case management team, the use of a common portfolio of resources, and its application to a pilot sample with an intervention period of 6-9 months.

Diseases (ICD-9), functional capacity, use of health and social resources, satisfaction, unit cost services.

There was an increase in the combined use of health and social resources in the intervention group, which included social day centers (21.8% in the intervention group compared to 9.8% in the control group), in coordination with primary care (suggested as the only health resource in 55.4% of cases). There was a decrease in the number of medical visits in the intervention group (43.6% versus 74.5% in the control group). Increased patient satisfaction (55.5% in the intervention group compared to 29.4% in the control group) was observed. At least an extra 4.4% of patients were treated using hospital resources without increasing costs.

Case management using a common unique portfolio of health and social resources can improve the coordination of resources, increases patient satisfaction and increases the capacity of using of hospital resources.