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Reduction of avoidable hospitalization rates: chronic disease management and care improvement


Chronic diseases are recognized today as the main contributor to morbidity, mortality and health-related costs in the world, including Brazil. The prevalence of chronic conditions continues to increase and is related to the ageing of population, presence of common risk factors, socioeconomic status and scientific advances. The cost of care of chronic conditions is increased considerably by its inadequate management. Several chronic care models have been developed, some of them with promising results. The present study will be composed of two phases. In the first one we will analyze the hospitalizations (rates and causes) and identify the avoidable ones. In the second phase it will be implemented a chronic care model for three of the most prevalent risk factors: hypertension, diabetes and dislipidemia. This model is constituted of a multi-professional team (nurses, pharmacists, dietitians) will use electronic mails, telephone contacts, group educational sessions to improve the quality of treatment offered. An interim analysis will be performed during the study. At the end of the implementation of a controlled model of care, we expect to spread this model to the units of basic care and to reduce significantly the cost of avoidable hospitalizations and the costs associated with the care of chronic illness. (AU)