Scaling integrated clinical pathways across Portugal's largest Local Health Unit

Coimbra Local Health Unit

Rather than treating that fragmentation as a limitation, ULS Coimbra is using it as the starting point for one of the country's most ambitious integrated-care programs, beginning with diabetes and expanding into depression, heart failure, chronic respiratory disease, and beyond.

+4200

Patients

50%

Engagement rate

+90%

Situations resolved remotely by the nursing team

Created in January 2024 as part of Portugal's reorganization of the National Health Service into Local Health Units (ULS), the ULS de Coimbra is the largest of the country's 32 new units.

Regional Insights:

365,275 residents across the ULS Coimbra's area of coverage, with roughly 410,000–415,000 registered patients;
Almost 8,000 km² of territory spanning 21 municipalities;
8 hospital units and 26 primary health centers;
More than 10,000 professionals, including over 2,200 doctors and 3,700 nurses;

Coimbra's scale is exactly what makes its fragmentation so consequential: a population that is older and more dispersed than the national average, spread across a territory nearly as large as some entire ULS regions, all needing to move coherently between family doctors, specialist hospital care, and community services that had historically operated as separate silos.

Problem

A historically siloed care model, in which primary care, hospital specialties, and community services functioned as disconnected units rather than a single system;
An aging, geographically dispersed population with a heavier chronic disease burden and higher mortality than the national average, straining a model built around episodic rather than continuous care;
A growing set of chronic conditions - diabetes and chronic obstructive pulmonary disease (COPD) chief among them - for which the existing pathways lacked a structured, proactive approach to prevention, monitoring, and follow-up;
Long-standing pressure on hospital emergency departments driven partly by chronic patients with no clear alternative pathway for care that could otherwise be managed and monitored closer to home.

Project Goals

Prevent chronic disease progression and improve quality of life for patients, while preventing avoidable complications;
Optimize the use of ULS Coimbra's available resources by giving chronic conditions a structured, evidence-based clinical pathway rather than managing them reactively, visit by visit;
Bring care closer to patients across all 21 municipalities, reducing unnecessary hospital displacement and reinforcing decentralized services;

“The platform helps us identify patients who really need our care, even in cases where they might not yet be aware of it themselves. ”

Luís Paixão

Family Physician

ULS Coimbra's Integrated Clinical Pathways (Percursos Clínicos Integrados, or PCI) are already live across several chronic conditions, with diabetes and chronic respiratory disease among the first to be implemented.

A multidisciplinary model built on evidence, anticipation, and efficient use of resources

Rather than a single tool bolted onto existing workflows, UpHill's Clinical Automation Platform is deployed as the backbone of how ULS Coimbra's integrated clinical pathways function day to day, built around three core ideas.

A multidisciplinary journey that coordinates care across levels

Each pathway is designed as a single journey that spans family medicine, hospital specialties, and community services, rather than a set of disconnected touchpoints a patient has to navigate alone. Care teams work from a shared, evidence-based protocol, so that a diabetes or respiratory patient moving between their family doctor, a specialist, and community follow-up experiences one coordinated plan rather than several separate ones.

2. Anticipating needs and preventing complications through automated monitoring

Rather than waiting for a scheduled appointment to find out how a patient is doing, the platform keeps a continuous, automated line of contact with patients between visits. This allows the care team to catch early warning signs and intervene before those signs become an avoidable complication or an emergency room visit.

“Continuous follow-up allows us to monitor how patients are doing. If we detect any change or irregularity in their clinical condition, we can act early, anticipating care and preventing the situation from worsening.”

Cidália Rodrigues

Medical Doctor, Pulmonology Specialist

3. Risk stratification and efficient use of resources

Not every patient needs the same level of attention at the same time. The platform supports the care team in stratifying patients by risk and clinical need, so that limited clinical time and resources are directed where they matter most, reserving in-person, specialist attention for higher-risk patients while lower-risk patients are followed more lightly, without either group falling through the cracks.

How this plays out in Coimbra: diabetes and chronic respiratory disease

In a region with an aging population - nearly half the patients served are elderly, and exposure to chronic disease rises accordingly - the goal across these pathways is to shift chronic disease management from a reactive, visit-by-visit model to one built on continuous follow-up. Structured digital touchpoints between scheduled appointments let the care team track how patients are managing their condition day to day, whether that's glucose control for a diabetes patient or breathing and symptom levels for a COPD patient, catching early signs of deterioration before they become emergencies. In-person time is reserved for the patients and moments where it matters most.

The same model is designed as a repeatable template across chronic conditions.

Solution details and highlights

UpHill's Clinical Automation Platform deployed as the backbone of ULS Coimbra's integrated clinical pathways, coordinating care across family medicine, hospital specialties, and community services;
Continuous, automated patient monitoring between scheduled appointments, enabling early detection of deterioration in diabetes and chronic respiratory disease;
Patient contact through multiple channels - chat, email, and voice AI - adapting to how each patient is most comfortable engaging;
Risk stratification that directs clinical attention according to patient need, rather than treating every case the same way;
A multidisciplinary implementation model, led by dedicated Working Groups combining family medicine, specialist care, and other disciplines;

Disclaimer

This data is specific to this use case at this institution and is presented as an example of how UpHill Route indirectly supports patient management processes in a context where clinical decision support systems are used. The institution itself collected the underlying data. UpHill Route does not claim any direct clinical benefit leading to readmission reduction, access increase, or unnecessary appointment reduction.

Move towards Patient-Centred care with UpHill

Talk to Sales