Abstract Body

Background and purpose

The Chronicity Management Team of the SAP Baix Llobregat Center works to guarantee comprehensive care for complex chronic patients in their environment. During the COVID-19 pandemic, the face-to-face activity of this team has been diminished, however a notable intensity of care has been maintained.

Methods

This team is made up of: two doctors and thirteen case management nurses (CG), in collaboration with professionals from the Primary Care Teams (PCT). The activity on complex chronic patients from the agendas of the population attended, with associated pathologies and socio-demographic data, has been collected from its own computer system. From March 2020 to December 2020 both included.

Results

For an assigned population close to 425,000 inhabitants, 10,051 were identified as complex chronic patients (5,746 women, 57%), with a mean age of 81 years. During this period 2393 people died, of which 552 attributable to COVID. Of the total, 723 were under close monitoring by the CGs of this team, of which 142 CRP + was detected for COVID in this period, of which 16 died. In total there were 64 were deaths. Of the total of complex chronic patients, 56,126 home visits were made (of which the CGs made 6,312, 12%) and 130,847 telephone calls (of which the CGs made 21,430, 16%). Hospital visits were reduced by 30% compared to the same period of the previous year.

Conclusions

The chronic care team, which represents 3.7% of all health professionals in this territory, has performed four times the amount of work on complex chronic patients, with a significant decrease in hospital pressure.