Effectiveness of a case management model for the comprehensive provision of health services to pluripathological patients

Interventions: The recruitment process will follow 2 ways: 1.Based on the characterization, the target population recorded in the database of the insurance health company will be invited to participate until the estimated sample size is completed. 2. During the hospitalization the patients can be detected and invited to participate into the study. In both, the informed consent will be a prior and required procedure.
The study will assess the outcomes in the same group of patients before and after intervention. The intervention follows the next steps:
1. Case detection: Identifying if the patient suffers from multiple diseases, if there are readmissions and high demand for health services during hospital stay or according to the reports of the health promoting entity (EPS in Spanish).
2. Case screening: assessing complexity INTERMED scale (European Consultation-Liaison Workgroup for General Hospital Psychiatry and Psychosomatic), medium-high or high).
3. To establish the baseline measurement of indicators to comparate during post-intervention.
4. Comprehensive and multidimensional assessment of the patient: identifying care needs.
5. Assessment of caregiver burden: identifying fatigue and general health status.
6. Personalized care plan: a comprehensive and individual plan is made for each case according to the needs detected.
7. Coordination between providers: contacts and procedures to secure referral to service providers as required by the patient and the family caregiver.
8. Monitoring and evaluation of the personalized plan.;Comprehensive Health Care;Patient Care Management;Long-Term Care;Delivery of Health Care ;Progressive Patient Care;Caregivers
Primary outcome(s): 1. Demand for health care services. (Frequency of use of health services for causes related to multi-pathological clinical categories, Measurement tool: Patients Database). Measurement time: At baseline and, 6 months.
2. Admission and re-admission (Frequency of unscheduled admissions and re-admissions related to multi-pathological clinical categories, Measurement tool: Patients Database). Measurement time: At baseline and, 6 months.
3. Pharmaceutical prescription (Medications prescribed to the patient,Measurement tool: drug-dispending database). Measurement time: At baseline and, 6 months.
Study Design: Allocation: Non-randomized controlled trial. Masking: Open. Control group: Historical. Assignment: Single group. Purpose: Prevention