Call for tender for project: Grants for Health Research and Development Projects. Basque Government Department of Health. 2024 call

Funding body: Basque Government Department of Health

Expediente: 2024111099

IP: Eduardo Millán

Funding awarded: 93.238,95€

Description: One of the strategic elements for tackling the challenge of chronicity in the Basque Country is to achieve effective population stratification based on health needs and to offer interventions tailored to these needs according to patient types. For patients with multimorbidity (PPP), the intervention consists of a care pathway whose effectiveness in real life has not been comprehensively evaluated. Determining its effectiveness will help to adjust and improve the strategy for identifying and intervening in PPP.

Objectives:

The main objectives of this project are (i) to determine the effectiveness of the corporate care pathway for PPP care in reducing the risk of hospitalisation, unscheduled hospitalisation, potentially avoidable hospitalisation, days spent in hospital, visits to hospital emergency services, risk of death and healthcare costs in this population; (ii) to determine its effectiveness in each of the main combinations of chronic conditions present in PPP and (iii) according to sociodemographic characteristics such as age groups, sex and socioeconomic status.

The secondary objectives are (iv) to determine the systematic variability in the effectiveness of the care pathway between different ISOs, and (v) to analyse associations between the main elements of the care pathway and effectiveness.

Expected results:  The project presented here is clearly oriented towards improving health, in this case that of one of the populations with the greatest needs and costs described in the literature, the multimorbid population (PPP), as this is a very complex population with significant healthcare needs, high hospitalisation rates and high mortality.

In addition, PPPs suffer more frequently from the negative consequences of fragmented, disease-focused care, and therefore require, more than any other population, person-centred, comprehensive care that is coordinated between the different professionals involved in the care process and between the different levels of care. In this regard, providing adequate care for this type of population has been and continues to be a priority in both the Basque Government’s Health Plans and Osakidetza’s Strategic Plans.

To this end, a great effort has been made in recent years to (i) identify the PPP population with the greatest needs and (ii) design and implement a corporate care pathway for PPPs, This has involved not only case-finding strategies within the Basque Country’s risk stratification system, but also the reorganisation of healthcare itself in the OSIs, dissemination and training efforts for both patients and carers, as well as for Osakidetza professionals, and the development of new roles within Osakidetza, such as advanced practice nurses, advanced competence nurses and reference internists.