title: Development of the Andalusian Registry of Patients Receiving Community Case Management, for the follow-up of people with complex chronic diseases.
abstract: OBJECTIVE
  Complex chronic diseases are a challenge for the current configuration of health services. Case management is a service frequently provided for people with chronic conditions, and despite its effectiveness in many outcomes, such as mortality or readmissions, uncertainty remains about the most effective form of team organization, structures and the nature of the interventions. Many processes and outcomes of case management for people with complex chronic conditions cannot be addressed with the information provided by electronic clinical records. Registries are frequently used to deal with this weakness. The aim of this study was to generate a registry-based information system of patients receiving case management to identify their clinical characteristics, their context of care, events identified during their follow-up, interventions developed by case managers and services used.
  
  
  METHODS
  The study was divided into three phases, covering the detection of information needs, the design and its implementation in the health care system, using literature review and expert consensus methods to select variables that would be included in the registry.
  
  
  RESULTS
  A total of 102 variables representing structure, processes and outcomes of case management were selected for their inclusion in the registry after the consensus phase. A web-based registry with modular and layered architecture was designed. The framework follows a pattern based on the model-view-controller approach. In its first 6 months after the implementation, 102 case managers have introduced an average number of 6.49 patients each one.
  
  
  CONCLUSIONS
  The registry permits a complete and in-depth analysis of the characteristics of the patients who receive case management, the interventions delivered and some major outcomes as mortality, readmissions or adverse events.
authors.affiliation: Faculty of Health Sciences, University of Málaga, Málaga, Spain.
authors.forename: Jose M
authors.initials: JM
authors.lastname: Morales-Asencio
authors.affiliation: Faculty of Health Sciences, University of Málaga, Málaga, Spain.
authors.forename: Shakira
authors.initials: S
authors.lastname: Kaknani-Uttumchandani
authors.affiliation: Faculty of Health Sciences, University of Málaga, Málaga, Spain.|District of Primary Health Care of Málaga-Guadalhorce, Andalusian Healthcare Service, Málaga, Spain.
authors.forename: Magdalena
authors.initials: M
authors.lastname: Cuevas-Fernández-Gallego
authors.affiliation: Case Management Area, District of Primary Health Care of Huelva-Costa, Huelva, Spain.
authors.forename: Leopoldo
authors.initials: L
authors.lastname: Palacios-Gómez
authors.affiliation: Case Management Area, Northern Málaga Health Care Management Area, Málaga, Spain.
authors.forename: José L
authors.initials: JL
authors.lastname: Gutiérrez-Sequera
authors.affiliation: Case Management Area, District of Primary Health Care of Almeria, Almeria, Spain.
authors.forename: Agustina
authors.initials: A
authors.lastname: Silvano-Arranz
authors.affiliation: Case Management Area, District of Primary Health Care of Jaen-Nordeste, Jaen, Spain.
authors.forename: Juan Pedro
authors.initials: JP
authors.lastname: Batres-Sicilia
authors.affiliation: Case Management Area, District of Primary Health Care of Cadiz-Bahia-La Janda, Cadiz, Spain.
authors.forename: Ascensión
authors.initials: A
authors.lastname: Delgado-Romero
authors.affiliation: Case Management Area, District of Primary Health Care of Sevilla, Sevilla, Spain.
authors.forename: Ángela
authors.initials: Á
authors.lastname: Cejudo-Lopez
authors.affiliation: Case Management Area, District of Primary Health Care of Granada, Granada, Spain.
authors.forename: Manuel
authors.initials: M
authors.lastname: Trabado-Herrera
authors.affiliation: Case Management Area, District of Primary Health Care Guadalquivir, Málaga, Spain.
authors.forename: Esteban L
authors.initials: EL
authors.lastname: García-Lara
authors.affiliation: Faculty of Health Sciences, University of Málaga, Málaga, Spain.|District of Primary Health Care of Málaga-Guadalhorce, Andalusian Healthcare Service, Málaga, Spain.
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Martin-Santos
authors.affiliation: Faculty of Health Sciences, University of Málaga, Málaga, Spain.|District of Primary Health Care of Málaga-Guadalhorce, Andalusian Healthcare Service, Málaga, Spain.
authors.forename: Juan C
authors.initials: JC
authors.lastname: Morilla-Herrera
mesh_terms: D000328:Adult; D019090:Case Management / Q000458:organization & administration* / Q000592:standards; D002908:Chronic Disease / Q000628:therapy*; D003153:Community Health Services / Q000458:organization & administration* / Q000592:standards; D015897:Comorbidity; D005260:Female; D006801:Humans; D020407:Internet; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000458:organization & administration* / Q000592:standards; D012042:Registries; D013030:Spain
keywords: case management; chronic disease; electronic health records; health care evaluation; health information systems; registries