Data_Sheet_1_Multicomponent, high-intensity, and patient-centered care intervention for complex patients in transitional care: SPICA program.PDF

Multimorbidity is increasingly present in our environment. Besides, this is accompanied by a deterioration of social and environmental conditions and affects the self-care ability and access to health resources, worsening health outcomes and determining a greater complexity of care. Different multidisciplinary and multicomponent programs have been proposed for the care of complex patients around hospital discharge, and patient-centered coordination models may lead to better results than the traditional ones for this type of patient. However, programs with these characteristics have not been systematically implemented in our country, despite the positive results obtained. Hospital Universitario de Canarias cares for patients from the northern area of Tenerife and La Palma, Spain. In this hospital, a multicomponent and high-intensity care program is carried out by a multidisciplinary team (made up of family doctors and nurses together with social workers) with complex patients in the transition of care (SPICA program). The aim of this program is to guarantee social and family reintegration and improve the continuity of primary healthcare for discharged patients, following the patient-centered clinical method. Implementing multidisciplinary and high-intensity programs would improve clinical outcomes and would be cost-effective. This kind of program is directly related to the current clinical governance directions. In addition, as the SPICA program is integrated into a Family and Community Care Teaching Unit for the training of both specialist doctors and specialist nurses, it becomes a place where the specific methodology of those specialties can be carried out in transitional care. During these 22 years of implementation, its continuous quality management system has allowed it to generate an important learning curve and incorporate constant improvements in its work processes and procedures. Currently, research projects are planned to reevaluate the effectiveness of individualized care plans and the cost-effectiveness of the program.

共病（Multimorbidity）在当今社会愈发普遍。此外，这一现象伴随而来的是社会与环境状况的恶化，并会影响患者的自我照护能力与健康资源可及性，进而恶化健康结局，加剧照护的复杂性。针对出院过渡期的复杂患者，学界已提出多种多学科、多组分照护方案；以患者为中心的协调模式相较传统模式，对此类患者可产生更优的照护效果。然而，尽管此类方案已取得积极成效，在该国却尚未得到系统性实施。西班牙加那利群岛大学医院（Hospital Universitario de Canarias）负责收治西班牙特内里费岛北部与拉帕尔马岛的患者。该医院内，一支由家庭医生、护士及社会工作者组成的多学科团队（multidisciplinary team），正针对照护过渡期的复杂患者实施一项多组分高强度照护方案——SPICA项目（SPICA program）。本项目以患者为中心的临床方法为指引，旨在保障出院患者的社会与家庭再融入，并提升其初级卫生保健（primary healthcare）服务的连续性。推行多学科高强度照护方案，可改善临床结局并具备成本效益，且此类方案与当前的临床治理（clinical governance）导向高度契合。此外，由于SPICA项目依托家庭与社区照护教学单元开展，用于专科医生与专科护士的培训，因此该项目也成为了在照护过渡期实践上述专科专属照护方法的实操平台。在项目实施的22年间，其持续质量管理体系助力项目形成了显著的学习曲线，并在工作流程与操作规范中不断融入改进举措。当前，团队正计划开展研究项目，以重新评估个体化照护方案的有效性与本项目的成本效益。