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Introduction:

Person centred care planning and models of care coordination across levels of care reduce fragmentation and unnecessary resource use. Our objectives were to assess the impact of implementing a coordinated care model between intermediate care and primary care, as determined by the identification of complex patients, and recording their individualized care plans in the shared medical record and to assess its effectiveness in relation to the use of health resources.

Methods:

A pre-post quasi-experimental study of 160 complex patients with dementia who were discharged from intermediate care between April 2022 and July 2024.

Results:

A 31.4% (from 63 to 106 patients) increase in the identification of complex patients with dementia and a 23.6% (from 19 to 44 patients) increase in the development of care plans were found at 3 months of discharge. Of the patients who had visited emergency department in the six months preceding hospitalisation, 54.4% (n = 31) did not visit it in the six months post-discharge (p = 0.026).

Conclusion:

Our coordinated care model may have contributed to improved identification of patients with dementia and complex conditions, the development of individualized care plans, and reduced emergency department use.