80-603 / Telematic Continuity of care in frail and / or vulnerable patients

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Andalusian Regional Ministry of Health and Social Welfare


Quality improvement project
Patient empowerment
Health IT
Implementation of Patient Safety initiatives / Activities
GOP Description
Implementation level
Clinical settings
Primary Care (Health Centers)
Hospital Care (inpatient units)
. To Ensure continuity of care and patient safety
2. To Improve accessibility
3. To Improve the effective management with the treatment: pharmacological, care / self-care, control of risk detected.
4. To Optimize the use of resources and services
5. To ensure quality of care and patient satisfaction and carers
There are groups of people in which the discontinuity of care is particularly unfavorable, as fragile patients are. To the introduction of this service, the fragility variables has been limited in: age, polypharmacy, comorbidity, absence of competent carers and basic activities daily life dependence
Tracking Protocols Using:
Nurses who monitor phone, have:Diagnoses algorithms
• early detection
Therapeutic OAlgoritmos *
• preventing problems
• early intervention
• referrals to family nurses
• referrals Coordinating Center of Emergency* Standardized language NANDA-NIC-NOC

The monitoring team is made up of one tele-operator located in “Salud Responde” (Andalusian Health System call center) for call forwarding to nurse team. It offers medical reference for any inquiries by the team nurse in emergency coordination center in each province.

Education and training of nursing staff for telephone follow-discharge

Information and training of nurses Andalusian Heatlh System Service Centers for recruitment of patients and the web application use.

Timeframe implementation
Implementation tools available
1. Web application for monitoring telephone from Andalusian Health System call center: “Salud Responde”
2. Design of Monitoring Protocols for discharged patients in home setting
3. Training the care team for continuity of care
4. Communication and information Plan for Health System Professionals
Implementation cost
Design and implementation of web application: 12.000 euros
Web Application support: From 8.000-10.000 euros/ year
Call Center Reference Team and Service: 1 tele-operator and 3 nurses + support services. 90.900 euros/ year
Method used to measure the results
Exploiting database available (from the web application for continuity of care)
System claims in the Andalusian Health System
1. Improve accessibility to professional reference for ensure continuity of care and ensure patient safety
2. Optimize the efficiency of health resources by automating and delegating protocolized actions to the telephone following team
• Reduce the use of emergency services
• Decrease hospital readmissions
3. Satisfaction of patients and caregivers
4. Satisfaction of the professionals involved: tele- continuity of care team, hospital equipment reference and primary care centers.
Analysis of the results
The positive results of effectiveness, efficiency, guarantee patient safety and improving accessibility and equity in care, have led to the use of this service to ensure continuity of care to other patient groups (ex : palliative care needs)
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
The greatest difficulty in its Implementation has been the identification and recruitment of people with Increased susceptibility to benefit from this service due to the resistance in some hospitals in the network to provide discharge in weekends, bank holidays or eve to patients under the conditions of fragility described.
Describe the strategies used to overcome the barriers (If needed)
Communication plan to address health centers on the success of the service and the patient and family satisfaction.
Other information
Other information about the GOP that you would like to add (Link or attached document)
Telecare service in the Andalusian Public Health System ensure continuity of care for frail or vulnerable patients discharged from Hospital inpatient units at weekends and holiday eves, by telephone follow-up interventions. The service is provided by a team of nurses with specific training in discharge telephone follow
When the patient’s situation meets these characteristics of fragility or vulnerability, the referring nurse activated phone continuity of care during the patient’s stay in hospital service, whether patient high-end occur weeks holidays or eve. Activation occurs during discharge planning, To do this, the nurse concerning the patient in the hospital enters relevant information to the home monitoring in a web application where this information can be accessed by telecare equipment
These teams maintain a proactive telephone contact before 24 hours after discharge and are available for patient or carer in resolving queries and connecting with other resources. After the weekend or holiday, the continuity of care is solved by the care teams (doctor-nurse) of primary care centers. These professionals access the application to view the information on the monitoring carried out by teams of telecare