Matosinhos Local Health Unit – Gold Winner of the Excellence Award for Leadership and Management

Date:  09 February 2024

Matosinhos Local Health Unit bagged the Gold title for the Excellence Award for Leadership and Management at the 2023 IHF Awards

Chronic Complex Patients (CCP) Support Team

Chronic Complex Patients (CCP) have risen in recent years amid the increase in life expectancy. These are elderly patients that have multi-morbidity and therefore need multiple medications. Support for these patients is often currently done in a fragmented way, with a high number of stakeholders. Therefore, this increases the risk of associated costs and unintended harm by medical interventions. These factors contribute to the need for a personalized and more effective response for this population. Responding to this problem means focusing on care integration and adopting strategies such as case management and the individual care plan as seen in practices within international health systems. In Portugal, the integration of care resulted in the formation of local health units, although only a few providers give whole-person care.

This prompted the Matosinhos Local Health Unit (ULSM) to form the Complex Chronic Patients Support Team (CCPST). Their aim was to integrate care and proximity response for complex chronic patients. The CCPST is a functional unit with the capacity to make home visits and with an open consultation available daily. Its basic principles are the integration of care, case management by nurses, multidisciplinary use of an individual care plan and close monitoring by internal medicine doctors.

The project’s priority was to improve the capacity of the patient and caregivers in the management of chronic illness by promoting knowledge and empowerment. The CCPST worked towards early diagnosis and treatment of acute situations with a reduction in the number of emergency episodes and hospitalization. They also focused on improving the quality of life for patients by keeping chronic diseases under control and managing expectations. CCPST prioritized implementing an integrated care model that promotes collaboration and continuity of care across settings, adopts patient-centered models, and prioritize preventive models. The team’s actions were geared towards providing regular visits to their users’ home by case manager nurses. They also conducted regular meetings with family health teams. Community effort was tapped through the creation of a volunteer pool, in partnership with the town council.

Developing community care through impact assessment

By October 2016, CCPST was created at the Matosinhos Local Health Unit (ULSM), taking advantage of the experience acquired by ULSM over the years on Integration of Care. The project started with a nurse working full-time at a Community Care Unit

(CCU) with an internist, working 6 hours a week. reality. In March 2017, the project was extended to another CCU, with the integration of another nurse, in addition to increasing the hours of the internist allocated to 24 hours per week. In October 2019, the program was able to cover the entire area served by the hospital with the admission of 3 more nurses. By March 2021, a second doctor was hired, with a 24-hour week workload. This period saw the team’s relocation to another building as they started a functional unit with its own cost center. In October 2021, another nursing element was integrated, allowing to improve the overall telephone management capacity and, at this moment, the current configuration of the team.

In the initial evaluation phase, several parameters were monitored including functional capacity, depression, adherence to the medication regimen, and quality of life among others. It was observed that there was a 63.3% drop in emergency episodes to 395 from 1,077 in the first year of implementation. Data also showed hospitalization episodes and hospitalization days declined by 61.6% and 64%, respectively. Within the patient cohort, more patients classified their quality of life to be better at the end of the year. Patients without depression or mild depression increased to 86,6% from 71.4%. Meanwhile, those with severe depression declined to 13.4% from 28.6%.

Find out more about the Matosinhos Local Health Unit

Matosinhos Local Health Unit - ULSM is a Corporate Public Entity, integrated in the National Health Service, which provides
primary and hospital health care. The philosophy of ULSM is to put the users at the centre of the system, to identify their
health needs and to meet them.

Call for entries for the 2024 IHF Awards open until 3 May!

Highlight your outstanding projects, programmes and services for a chance to be recognized on a global stage.

Written by:

Eleonor Angeles

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