Closing the distance: proactive, person-centered care for chronic respiratory disease

ULS Litoral Alentejano (Local Health Unit)

Closing the distance: proactive, person-centered care for chronic respiratory disease in the Alentejo Litoral

Built as part of a broader Integrated Care Pathway for People with Multimorbidity, Consigo reflects the scale and geography of the region it serves.

Spread across one of the most sparsely populated and geographically extensive health regions in mainland Portugal, the Unidade Local de Saúde do Litoral Alentejano (ULSLA) faces a challenge many urban health systems don't: distance itself is a barrier to care. CONSIGO, its integrated care program for people living with Chronic Obstructive Pulmonary Disease (COPD), is ULSLA's answer, designed around proactive chronic disease management, prevention of decompensations, and proximity to patients wherever they live.

Regional Insights:

An estimated 100,000 residents across the 5 municipalities served by ULSLA;
More than 5,300 km² of territory, one of the largest and most dispersed catchment areas of any local health unit;
1 hospital and 5 primary health centers, one per municipality;

Problem

A still largely reactive model for managing chronic disease, particularly for conditions like COPD that require continuous, proactive follow-up rather than episodic care;
Significant geographic inequities in access to care;
A fragmented experience for patients with multimorbidity, who often need coordinated input from multiple specialties and levels of care without a clearly defined, shared pathway to guide that coordination;
Limited structured support for patients and caregivers to self-manage a chronic condition like COPD between clinical contacts.

“This program is vital because COPD has a significant social and economic impact on patients, many of whom are still working. By focusing on a proactive approach, the program helps us manage their care effectively and address their needs before they experience serious health complications.”

Teresa Bernanrdo

Medical Doctor, Internal Medicine Specialist

Project Goals

Shift the paradigm in chronic disease management from reactive to proactive, with earlier detection and prevention of decompensations;
Overcome geographic barriers, particularly for patients in more isolated parts of the region, through remote monitoring and communication;
Establish a cohesive, sustainable, continued, and person-centered care network for people living with COPD;
Build the capacity of patients and caregivers to self-manage chronic disease through structured education and ongoing follow-up.

Consigo sits within ULSLA's broader Integrated Care Pathway for People with Multimorbidity, reflecting a deliberate bet on care integration as a response to a population with rising chronic disease needs.

Patients diagnosed with COPD are identified and followed along a care journey that defines the most appropriate approach for each person, based on multidisciplinary assessment and individual risk stratification - a mapped, defined, and shared pathway across ULSLA's units, delivered through a digital format that keeps the same information available to every team, in every unit, at every point of contact.

A proactive, close-to-home model built on coordination, anticipation, and efficient use of resources

1. A multidisciplinary journey that coordinates care across levels, and keeps it close to home

CONSIGO brings together doctors, nurses, physiotherapists, and cardiopulmonary technicians around a single, shared care journey for each patient. The pathway itself is digital, mapped, and shared across all of ULSLA's units, so that every team has the same information available to make the best decisions for each patient, wherever in the region that patient is being seen. Because that journey is shared and clearly defined, primary care teams can take on the ongoing management of a COPD patient without the patient needing to travel to the hospital every time.

2. Anticipating needs and preventing complications through automated monitoring

Rather than relying solely on scheduled visits, Consigo uses remote monitoring and communication strategies to keep a continuous line of contact with patients between appointments. This reduces the geographic inequities that would otherwise limit access, and allows the care team to detect changes in a patient's condition early enough to act before they escalate.

3. Risk stratification and efficient use of resources

Not every patient needs the same level of attention at the same time. By knowing exactly which patients are stable and which need closer attention, and what kind of care they need, the multidisciplinary team can direct each person toward the most appropriate level of care.

“This digital care journey helps us stratify and identify patients with COPD, and the automation capabilities enable us to detect stable patients and those who require more personalised care”

Víctor Gomes

Rehabilitation Specialist Nurse

4. Empowering patients to self-manage their condition

CONSIGO treats patient and caregiver education as a core part of the pathway, not an add-on. Through in-person and remote health literacy support, patients build the knowledge and skills to manage a chronic condition like COPD in their everyday lives: recognizing warning signs, understanding their treatment, and feeling less at the mercy of the disease between clinical contacts. For a condition patients often live with for decades, that shift, from passive recipient of care to active participant in managing it, is as central to the program's goals as any clinical intervention.

“Self-management, specifically, means enabling patients to oversee their own medication, keep symptoms such as shortness of breath and anxiety under control, build their physical capacity, and adopt a healthier lifestyle overall.”

Carla Cruzinha de Sousa

Physiotherapist, Consigo Program Coordinator

How this plays out in the Alentejo Litoral: chronic respiratory disease (COPD)

For a condition like COPD, with a growing economic and social impact, and a heavy toll on patients' quality of life, CONSIGO organizes care around three pillars of disease management: smoking cessation, as the only way to halt disease progression; pharmacological therapy, using inhaled bronchodilators to ease symptoms like breathlessness and reduce the inflammatory burden that drives exacerbations; and non-pharmacological care, including ventilatory technique training and aerobic and muscular conditioning, which, practiced regularly, is associated with real gains in patients' day-to-day capacity to live with the disease.

The program's education and health literacy component, delivered both in person and remotely, is central to that third pillar, reinforcing the self-management focus described above.

Solution details and highlights

UpHill's Clinical Automation Platform deployed as the digital backbone of ULSLA's Integrated Care Pathway for People with Multimorbidity, starting with COPD through the CONSIGO program;
A single, shared, digital care journey spanning doctors, nurses, physiotherapists, and cardiopulmonary technicians, replacing ad hoc coordination between specialties;
Proximity care built into the model: primary care teams can manage COPD patients on an ongoing basis without routine hospital travel;
Remote monitoring and communication designed specifically to offset geographic inequities in a region spread across more than 5,300 km²;
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, distinguishing stable patients from those requiring closer follow-up;
A strong patient and caregiver education and health-literacy component, delivered in person and remotely, empowering patients to self-manage a chronic condition between clinical contacts;
Designed as part of a broader, repeatable model for multimorbidity care — not a standalone program limited to a single condition.

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.

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