Background And Objective: Patients with chronic conditions are often readmitted to hospital. A study was designed to improve health care to these patients.
Patients And Methods: Patients attended at the Internal Medicine Department of a hospital area who were admitted to hospital at least three times in a year were included in the study. Within a prospective study, patients were attended by means of specific consultation with care upon request and telephone care, with the possibility of programmed admission.
Results: Patients were followed for 32 months, with a 45% decrease in the admission rate, 50% in visits to the Emergency Department, and 26% in hospital stay days.
Conclusions: The proposed care model decrease the attending needs for these patients.
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