Care integration: keeping patients on the radar to provide the right care, at the right time

ULSLA (Litoral Alentejano Local Health Unit)

The growing population of individuals with chronic conditions, demanding sustained engagement with the healthcare system and comprehensive interdisciplinary care, underscores the importance of integrating care to enhance both the quality of healthcare services and operational efficiency within healthcare units. Find out how UpHill has boosted the work of Unidade Local de Saúde do Litoral Alentejano (Litoral Alentejano Local Health Unit) by digitizing and automating the care journey for people with heart failure.

+ 1300

communications sent

+ 85 hours

of workload saved

+ 70%

patient adherence

Unidade Local de Saúde do Litoral Alentejano (ULSLA) comprises one secondary hospital (Hospital do Litoral Alentejano) and five health centers. Beyond the inherent complexities of coordinating care journeys across these varied contexts, the institution faces additional challenges: with a patient base exceeding 105,000, approximately 25% of whom are aged over 65, distributed across an expansive 5,300km², effective chronic disease management becomes a paramount concern.

Chronic diseases commonly manifest as recurring episodes of decompensation, marked by a distinctive pattern wherein individuals rarely revert to their initial baseline even after recovery. Consequently, healthcare delivered in episodic, time-bound intervals, without accounting for the dynamic and unpredictable nature of clinical progression, falls short in meeting the demands of such patients.

The main focus in managing these cases revolves around proactive measures to prevent decompensation. This demandes for care restructuration, incorporating early identification signals for potential decompensation, ensuring prompt access to essential care for individuals, and fostering cohesive coordination across diverse healthcare levels.

In response to resource limitations and the imperative to minimize geographical barriers, ULSLA's clinical and management teams have demonstrated notable dedication in addressing these challenges, making ULSLA an example in care integration.

Project goals

Ensure care consistency and support clinical decisions based on the best evidence;
Improve effective collaboration between teams by increasing patient visibility over the entire journey and breaking down information silos;
Identify heart failure exacerbations timely by improving follow-up approach;
Refer patients to the appropriate level of care according to their risk;
Prevent avoidable visits to the Emergency Department or hospitalizations;
Improve patient experience and safety;

Solution

UpHill's solution on chronic diseases was applied to optimize care integration, both addressing patients and healthcare teams needs.

Through its implementation, ULSLA has digitalized the care pathway for heart failure patients, establishing a standardized approach across primary care and hospital settings. This initiative ensures seamless visibility into the patient's status and facilitates information sharing among all healthcare professionals. Additionally, an automated mechanism has been introduced to systematically monitor and track the progress of all patients in the system.

Multidisciplinary and multi-level care journeys supported by a digital care pathway

The ULSLA digital care pathway for heart failure represents a comprehensive intervention designed to provide continuous and multidisciplinary medical care. Initiated through a consensus document, this framework delineates specific actions, decisions, and diagnostic, treatment, follow-up, and referral criteria for heart failure patients. The document serves as a robust support system for evidence-based interventions, both by primary care teams to hospital teams, facilitating the translation of recommendations to the local level.

“Clinical pathways enable the optimization of clinical practices, rooted in established guidelines, within the most effective organizational framework for a given institution. This ensures that patients receive the right care, at the right time, and in the most suitable care setting for each specific situation.”

Adelaide Belo, MD

Case Management Project Coordinator

Decision support system standardizing best practices

UpHill software provides healthcare professionals with real time and evidence-based recommendations, ensuring consistent care and improving decision-making. In primary care, this is specially relevant to upskill generalist physicians and, regarding nursing teams it also enhances autonomy. Clear referral criteria within the predefined care journey ensure appropriate specialist referrals, minimizing unnecessary ones and improving overall healthcare efficiency.

“The clinical decision support tool is indispensable due to the intricacies of the heart failure protocol, which is characterized by numerous specificities contingent on clinical situations. Given the impracticality of consulting the document continuously, the decision support tool not only aids professionals in decision-making but also support them in making the best decision. And that decision is made anywhere, wherever the patient is.”

Inês Coimbra do Vale, MD

General and Family Medicine

Task automation increasing capacity and real time monitoring enabling prioritization

UpHill enables ULSLA to automatically monitor patients' health status, track vital indicators, and identify individuals in need of immediate attention or urgent interventions. This proactive methodology facilitates timely interventions, averting potential complications. By promptly alerting healthcare teams to critical changes in a patient's condition, the system empowers them to prioritize and allocate resources effectively.

“The availability of automatic alerts triggered by patients' or caregivers' responses to the signs and symptoms questionnaire administered by the virtual assistant empowers us to proactively anticipate instances of decompensation and potential visits to the emergency room or hospitalization.”

Mónica Santos

Nurse | Member of the Coordinating Center for Care Pathways

Interoperability capabilities linking systems

UpHill integrates with existing information systems. Our interoperability capabilities ensure that all teams, in all care settings, have exactly the same information about the patient and know in real time what has been done and which are the next steps.

“This automated journey means that, at any time, the patient can be inserted into the pathway or activated in the phase and context in which he or she is. Once engaged in the pathway, any healthcare professional accessing the platform gains real-time visibility into the patient's current status. Previously, this capability was unattainable.”

Teresa Bernardo, MD

Head of Ambulatory Medicine Unit

Solution details and highlights

Evidence-based care pathway adjusted to local reality.
Decision support system with step by step pathway interaction.
Patient data storage on top of the decision support system.
Automatic follow-ups using an omnichannel approach and familiar patient channels (SMS, phone call and email).
No invasive medical devices or procedures.
Use of validated and automated questionnaires and scores, namely LACE Index for Readmission.
Automatic patient stratification through according to risk.
Intelligent application of the information collected to update patient status.
Automatic alert generation to warn health teams on patients’ red flags.
Real time visibility and significancy on automated actions.
Interoperability capabilities linking different systems reducing tasks repetition.
Compliant with relevant industry-standard certifications.

“[Through this project] our goal is to ensure that the population within our 5,300 kilometer span experiences healthcare accessibility comparable to that of Matosinhos, where even the furthest primary care unit from the hospital is approximately 16 kilometers away and conveniently situated near a subway station.”

Catarina Filipe

Chairman of the Board of Directors

Impact and Insights

+500 patients included in 6 months
Average age of 77 years old
+100 healthcare professional using the software
+1300 communications sent
70% patient adherence
85 hours of healthcare professional workload saved
95% of alerts solved before the expected time