Complex Care Support Team

The Complex Care Support Team, launched in February 2017 as part of the Casernes - Vall d’Hebron Hospital Primary Care Service, is an early intervention, personal and proactive outpatient service for those with complex chronic care needs at risk of aggravation within the AIS Nord districts. It is based on a new organisational model promoted by Barcelona Primary Care Services and Vall d'Hebron Hospital. The aim is to provide comprehensive intermediary and intensive outpatient care to people prone to instability and with a history of regular visits to A&E or admissions to hospital.

Located in the Sant Andreu district of Barcelona, the 800 m2 centre has 8 consulting rooms, which can be increased to 16, as well as 4 hospital beds available without having to be admitted through A&E.

Aims

• Preventing organ failure and complications.
• Reducing potentially avoidable readmissions and hospitalizations.
• Reducing visits to A&E.
• Preserving patients’ ability to function and quality of life.
• Improving patients’ and their families’ perceived level of satisfaction.

What services does the unit provide?

• Comprehensive patient assessment.
• Multidisciplinary intermediary care with the following optional procedures available:
  • Monitoring of vital signs.
  • Treatments administered intravenously and by perfusion.
  • Collection and extraction of samples (lab or microbiology).
  • Electrocardiogram.
  • Standard radiology.
  • Complex treatments, catheters and drainage bags.
  • Oxygen therapy and nebulization.
• Guaranteed continuation of care via:
  • Agreement and adjustment of the Treatment Plan.
  • Coordination with the patient’s Primary Care Team.
  • Coordination with the different hospital or community care healthcare teams the patient requires as an outpatient.
  • Case management.
• Provision of supporting healthcare education for the patient.
• Support for family and carers.