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Complex Care Support Team

Early intervention, innovative and proactive service for patients with complex chronic care needs

 

A multidisciplinary team of professionals from primary care services and Hospital Vall d’Hebron, working together with a shared objective.

Presentation

The Complex Care Support Team, launched in February 2017 as part of the Casernes - Vall d’Hebron Hospital Primary Care Service, is an early intervention, personal and proactive outpatient service for those with complex chronic care needs at risk of aggravation within the AIS Nord districts. It is based on a new organisational model promoted by Barcelona Primary Care Services and Vall d’Hebron Hospital, and aims to provide intermediary integrated and intensive outpatient care to people prone to instability and with a history of regular visits to A&E or admissions to hospital.

Located in the Sant Andreu district of Barcelona, the 800 m2 centre has 8 consulting rooms, which can be increased to 16, as well as 4 hospital beds available without having to be admitted through A&E.

 

Aims

  • Preventing organ failure and complications
  • Reducing potentially avoidable readmissions and hospitalizations
  • Reducing visits to A&E
  • Preserving patients’ ability to function and quality of life
  • Improving patients’ and their families’ perceived level of satisfaction

 

What services does the Unit provide?                 

  • Comprehensive patient assessment

  • Multidisciplinary intermediary service with the following optional procedures available:

    • Monitoring of vital signs

    • Treatments administered intravenously and by perfusion Collection and extraction of samples (lab or microbiology) Electrocardiogram

    • Standard radiology

    • Complex treatments, catheters and drainage bags Oxygen therapy and nebulization

  • Guaranteed treatment continuity through:

    • Agreement and adjustment of the Treatment Plan

    • Coordination with the patient’s primary care team

    • Coordination with the different hospital or community healthcare teams the patients requires as an outpatient

    • Case management

  • Provision of supporting healthcare education for the patient

  • Support for families and carers

Where to find it

Equip de Suport Integral a la Complexitat (ESIC) Casernes - Vall d'Hebron