Social Health Diagnosis as a complementary tool in the clinical diagnosis for the integrated approach of the CCP in a FUCP addressed to the direct attention of CCP with heart failure (HF) and chronic obstructive pulmonary disease (COPD)

Introduction : Within the scope of the Health Plan, the paradigm of health care aimed at CCP is the integrated work. Any healthcare action continues beyond the healthcare system and it is projected on the social context of the patient. Nonetheless, there's not very much clinical information related to this topic. Objectives : The main objective of Social Care in the FUCP has been its active participation as a member of the team in assessing the CCP to provide comprehensive assesment, knowledge of the circumstances that condition treatment, patient recovery and therapeutic decisions. Active participation through an individualized study of all CCP by this Unit performing primarily social assessment in cases that are likely to be of social risk, is detected in an objectified way by any team member or it is assessed by the Gijon scale of socio-familiar assessment and / or Barber scale. Likewise, we aim at strengthening and streamlining cross and net coordination in the social area to activate the resources or social strategies, acting as catalysts and promoting cooperative approach. Work Plan : The role of social work in the FUCP has been focused on the need to expand the vision of comprehensive care, to treat beyond physical health. Social factors can aggravate their condition and care at home. This is a much more complex approach which analyzed the patient's environment, proposing and negotiating strategies with patients, their caregivers and the team. Our main tool has been the personal and / or family interview and observation of the dynamics of relationship and interaction of the patient. We use the joint visits to assess each case and to define a care plan (PIIC; Individualized Integrated Plan for Chronic Patient) with patients and families. Project Results : During 2013, 103 CCP patients were treated by the FUCP in CAP Mutua Rubi with HF and / or COPD (who had been admitted to hospital twice or more for decompensation in their main pathology in the last 12 months). In 2014 there were 198 CCP divided by clinical criteria for chronicity and complexity,maintaining active follow-up of CCP and CHF and / or COPD. In 2013 for the study and assessment of the CCP by the Social Worker (SW) 56 first visits were conducted , 104 follow-up visits, 46 phone calls, 39 home visits and 211 processing and management of requests . In 2014 (and up to May 2014) 19 first visits, 53 follow-up visits, 45 phone calls, 19 home visits and 55 processing and management of requests were recorded. At the end of 2013 the SW studied 70 of these CCP, detecting social needs of the patient or the environment in 57 cases (81.42%): in 16 of these 70 cases (22.85%) there was no family support; in 3 of the cases this support was inadequate (4.28%); in 8 cases (11.43%) despite being supported, the caregivers presented risk of abandonment and in 3 of this 8 cases the caregivers gave up in the last moments. In 4 cases the family was supported by a fragile partner (5.71%), in 4 cases a poor family relationship before the disease was detected, and there was mistreatment in 1 case. We perform a day-to-day approach to give a solution to the characteristic fluctuation and frequent worsening of our patients. Despite programming the follow-up, when coordination with other services is needed (at home care services, sub-acute, emergency servicies, etc.) response time is performed in a maximum of 48 hours. Discussion / lessons learned : Social diagnosis of FUCP allows specific actions to be carried out with the patient and their environment, identifying social risk situations affecting their health. The multidisciplinary and comprehensive assesment done from primary care to the hospital and the health and social services is effective and necessary to ensure successful CCP care. Likewise, it reduces hospital admissions and emergency room visits sometimes generated not so much by the disease itself, but for the abandonment or caregiver anxiety. Fernandez Vargas, A. M. et al. detected outstanding social information in COPD patients and consistent with our results; More than a half of patients referred to have an acceptable social support (61%). A considerable percentage of family disfunction was found (17.4%), and severe disfunction in 2.9%. Brief summary of experience : Social health diagnosis is a complementary tool in the clinical diagnosis for the comprehensive approach of the CCP. Social assessment and social work is of utmost importance both for the CCP as well as the caregivers to ensure the success of comprehensive care, and cross-multidimensional CCP.