Development and evaluation of an Innovative Chronic Disease Management Program in Valencia-La Fe Health Department

Valencia La Fe-Health Department, aligned with the Regional Ministry of Health, is pushing an Innovative Chronic Diseases Management Program, by introducing a new, proactive, care model based on current policies, best practices and evidence available aiming to a greater control of the patients while they are at homes. The program has been developed working on the seven courses of action, covering all the components required according to experts. This includes a) identification and stratification of the population, b) care processes design in coordination with all health care resources involved according to case management methodology, c) guidelines and protocols documentation and design of educational programs, d) Service portfolio development and care planning and coordination across care level e) promotion of new technologies, f) continuous assessment and improvement of quality of care g) alignment of resources and incentives in the Health Department. The predictive model developed identifies 3.28% of the total population, related to 72% annual consumption of unplanned weighted resources in our reference population. Chronic management program was evaluated through both a quasi-experimental study including 1900 patients enrolled in the case management program and a randomized clinical trial (RCT) including 495 patients on 3 branches (standard practice, phone supported intervention and technology based intervention). RCT preliminary results regarding health-related quality of life and other outcomes variables will be available during the first quarter of 2014.