Impact of an integrated transitional care programme for older patients with multimorbidity and repeated emergency...

With an ageing population, the prevalence of multimorbidity is increasing. This leads to increasing frailty and repeated Emergency Department (ED) visits. This study aim was to evaluate the impact of an integrated transitional care programme on ED revisits and Health-Related-Quality-of-Life (HRQoL) in older patients with multimorbidity.

Prospective intervention pre-post study comparing the programme impact 6 months before and 6 after launching (from November-2022 to June-2023). The programme involved automated daily lists, a patient distribution protocol and a specialized case - manager nurse. Patients included had two or more ED visits in the 6 months prior due to Heart Failure (HF) decompensation or Chronic Obstructive Pulmonary Disease (COPD) exacerbation with multimorbidity. The programme involved the tertiary, intermediate and primary care centres of an integrated care health area of a Spanish city.

In 126 older patients with multimorbidity and repeated ED visits (91 HF, 29 COPD, 6 both), an integrated transitional care programme resulted in a significant 33% reduction in ED visits after six months. The reduction was higher among women (39.6% reduction vs 27.6% in men) and patients experiencing HF (38.7% vs 17.2% in COPD). Most participants (68.2%) reported an improvement or maintenance of quality of life.

A combined intervention between automated lists, territorial consensus, and a specialized case-manager nurse is efficacious to achieve ED re-visits decreases with a majority of patients having maintained or improved HRQoL.