Rev Med Liege. 2025 Sep;80(9):584-591.
ABSTRACT
Patients with complex care needs present numerous challenges: the care they receive is often associated with more hospital admissions. The care provided to this group could benefit from being more goal-oriented and better integrated. However, strengthening a net-work of care for these patients starting from hospitalization remains a challenge. This is particularly due to the fact that available assessment tools poorly reflect patient overall needs, especially psychosocial ones, and do not help identify their priorities.Therefore, we implemented a care strategy that includes the use of the ELADEB tool combined with the intervention of a case manager. We present the results of a retrospective study using administrative data from 109 hospitalized patients. We measured the effect of this intervention by comparing the number and duration of hospitalizations, as well as the number of readmissions within 30 days of discharge, one year before the intervention and one year after. We observed a statistically significant decrease in unplanned hospitalizations, average lengths of stay, and readmissions in the year following the intervention. These exploratory results highlight the potential value of such an intervention, yet a rigorous prospective evaluation in our context remains to be done.
PMID:40931734
