81-603 / Telematic Continuity of care in palliative care 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 (Home Environment)
Hospital Care (inpatient units)
To Ensure continuity of care and patient safety
prevention and relief of suffering
effective management of treatment, self-care, control of risk detected and early emergency intervention
To Improve accessibility
To Improve the.
To Optimize the use of resources and services
To ensure quality of care and patient satisfaction and carers
Palliative patients and caregivers
Tracking Protocols Using:
Nurses who monitor phone, have:Diagnoses algorithms
• early detection
Therapeutic algorithms*
• 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 in a 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
2 years
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
Web Application support
Call Center Reference Team and Service
Comunication Plan and TrainingTotal Cost 145.000 euros
Method used to measure the results
Exploiting database available (from the web application for continuity of care)
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
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
This service continues its implementation process this year so when this phase ends we will analyze the results that have been obtained to redirect subsequent developments
Describe the strategies used to overcome the barriers (If needed)
There is no specified text here
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 palliative care patients by the development of a web application to implement a program for monitoring and allowing the access to patients in need of palliative care and caregivers, favoring quality palliative care. This initiative is part of the right to die with dignity guaranteed by the Statute of Andalusia for citizens

Through the Andalusian Health System call center service (“Salud Responde”)and in coordination with professionals, the Ministry of Health offers a 24 hours service with personalized monitoring and ongoing patients who are in the final phase of life.

The service is provided by a team of nurses with specific training in discharge telephone follow.

This service is based in these three points:
a. The reagent Health Council on overview reasonable doubt. It is not necessary to be included in the platform.

b. Inclusion of terminal patients discharged from inpatient units.in telecare service
c. – Maintain the continuity of care of the terminal patients at home, in discontinuity of care periods: evenings, nights, holidays, weekends …..