Integral Clinical Plan Shared With or Without Telemonitoring of Constants in Patient With Chronic Diseases (ATLAN_TIC01)
Chronic Lung Disease, Chronic Heart Disease
About this trial
This is an interventional supportive care trial for Chronic Lung Disease
Eligibility Criteria
Inclusion Criteria:
- Majority legal age (18 years of age or older)
- Present any of the following shortcomings:
Heart failure with baseline dyspnea ≥III of New York Heart Association (NYHA) Chronic respiratory insufficiency with basal dyspnea ≥III of Medical Research Council (MRC) Scale and / or oxygen saturation <90% and / or home oxygen therapy.
- Present Heart Failure or Respiratory Insufficiency with basal dyspnea grade <III (according to NYHA and MRC respectively) but have presented 2 or more income in the last year.
- Score of Patients with terminal or palliative medical diseases (score PALIAR) index between 0 and 7 points.
- To present one of the following assistance situations: hospital admission, follow-up in Home Hospitalization or Palliative Care Teams, specialized outpatient follow-up.
- Speak, understand, read and write Spanish, either the patient or the primary caregiver.
- Have basic knowledge of the use of mobile phones and applications of computer tablets (such knowledge will be confirmed by personal interview, with test of the device).
- Informed consent to participate in the study
Exclusion Criteria:
- Presence of malignant neoplastic disease ACTIVE except localized adenocarcinoma of prostate in hormonal treatment, and / or cutaneous basocellular-squamous cell carcinoma.
- In the case of Chronic Renal Disease if there is the possibility of entry into Substitutive Therapies (hemodialysis or transplantation)
- In the case of chronic liver disease, if there is a possibility of liver transplantation.
- Chronic neurological disease with established cognitive impairment (E. Pfeiffer with 7 or more errors and / or Mild cognitive evaluated (ECM with ≤18 points).
- Clinical situation of agony.
- Surprise question ("Would you be surprised if your patient died in the next 6 months?") With the result "I would not be surprised" + PALIAR Score Score ≥7.5 points.
- Participate in another tele-health initiative.
- Go simultaneously to a private health service and / or be institutionalized
Sites / Locations
- Serranía de Ronda Hospital
- Universitary Hospital Virgen Macarena
- Universitary Hospital Virgen del Rocío
- Complejo Hospitalario de Jaén
- Hospital Universitario de Valme
Arms of the Study
Arm 1
Arm 2
Other
Other
Tele-monitoring Constant
Standard clinical care
To analyze the efficacy and cost-efficacy of incorporating tele-monitoring of bio-parameters into the shared comprehensive clinical care plan. Patients will receive in their home a kit consisting of a briefcase containing all equipment (scale, pulse-oximeter ... etc) and a logo access to devices (Tablet) through mobile communications m2m between patient and platform Management for Chronic Patients.
Standard clinical care plan shared between plan of attention to the patient with Pluri-pathological process and the care plan for patients with chronic diseases, based on a comprehensive clinical assistance shared between Primary Care and Hospital Care