title: [Continuity of care from the acute care hospital: Results].
abstract: OBJECTIVE
  To describe the profile of patients treated by a Continuity of Care Manager in an acute-care center during the first six months of its activity, as well as the profile of patients treated and the resource allocation.
  
  
  METHODS
  A prospective cross-sectional study was conducted on patients with complex care needs requiring continuity of care liaison, and who were attended by the Continuity of Care Nurse during the period from October 2013 to March 2014. Patient characteristics, their social environment and healthcare resource allocation were registered and analyzed.
  
  
  RESULTS
  A total of 1,034 cases of demand that corresponded to 907 patients (women 55.0%; age 80.57±10.1; chronic 47.8%) were analyzed, of whom 12.2% were readmitted. In the multivariate model, it was observed that the variables associated with readmission were polypharmacy (OR: 1.86; CI: 1.2-2.9) and fall history prior to admission (OR: 0.586; CI: 0.36-2-88).
  
  
  CONCLUSIONS
  Patients treated by a Continuity of Care Nurse are over 80 years, with comorbidities, geriatric syndromes, complex care, and of life needs, to whom an alternative solution to hospitalization is provided, thus preventing readmissions.
authors.affiliation: Gestión de Continuidad de Cuidados, Hospìtal Universitari de Vic, Hospital Universitari de la Santa Creu de Vic, Barcelona España. Electronic address: msole@hsc.chv.cat.
authors.forename: Montserrat
authors.initials: M
authors.lastname: Solé-Casals
authors.affiliation: Unidad de Epidemiología Clínica, Hospital Universitari Vic, Barcelona, España.
authors.forename: Emilia
authors.initials: E
authors.lastname: Chirveches-Pérez
authors.affiliation: Metodología de Cuidados, Hospital Universitari de Vic, Barcelona, España.
authors.forename: Anna
authors.initials: A
authors.lastname: Alsina-Ribas
authors.affiliation: Unidad de Epidemiología Clínica, Hospital Universitari Vic, Barcelona, España.
authors.forename: Emma
authors.initials: E
authors.lastname: Puigoriol-Juvanteny
authors.affiliation: Metodología de Cuidados, Hospital Universitari de Vic, Barcelona, España.
authors.forename: Margarita
authors.initials: M
authors.lastname: Oriol-Ruscalleda
authors.affiliation: Dirección de Cuidados, Hospital Universitari de Vic, Universitat de Vic, Barcelona, España.
authors.forename: Mireia
authors.initials: M
authors.lastname: Subirana-Casacuberta
mesh_terms: D000369:Aged, 80 and over; D003266:Continuity of Patient Care; D003430:Cross-Sectional Studies; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D011446:Prospective Studies
keywords: Advanced nurse practice; Case management; Chronic disease; Complejidad; Complexity; Continuidad de la atención al paciente; Continuity of patient care; Enfermedad crónica; Enfermera de práctica avanzada; Evaluación de necesidades; Gestión de casos; Needs assessment