CARDIAC INTEGRATED CARE: participatory research in care transition processes and therapeutic self-care in people after acute myocardial infarction study protocol

Cardiovascular disease is the main cause of death and incapacity in Portugal. With population ageing and greater survival to initial events, the burden of incapacity-adjusted life years tends to increase, representing a growing challenge for health systems. Patients with cardiovascular disease travel quickly through healthcare systems, with brief interactions, by a variety of healthcare professionals, so is critical to rethinking care approaches. Integrated care has shown to be effective for patients with chronic conditions, associated with reduced hospitalizations and related costs, and increased patient satisfaction, perceived quality of care, and access to care. CARDIAC INTEGRATED CARE project aims to develop and test an integrative care project between cardiology and primary healthcare, using participatory decision-making to improve care transition processes and promote therapeutic self-care in people after acute myocardial infarction (AMI). Using Participatory Health Research methods, patient with AMI and health professionals (nurses, cardiologists and pharmacists from hospital, nurses, general practitioners and pharmacists from PHC) will be engaged through all stages: "AMI Integrated Care Pathway" cocreation, implementation training and efficacy evaluation. When "AMI Integrated Care Pathway" cocreated, it will be validated through Delphi Method by Portuguese Cardiology Society and Portuguese Health Quality Department. The stage of implementation involves healthcare professionals training in post AMI referral and surveillance, from Cardiology and selected primary healthcare centres. Finally, the proposed ""AMI Integrated Care Pathway"" will be evaluated on the last stage, through a quasi-experimental study with two groups: experimental group will include post AMI patients discharged from hospital cardiology and belonging to the selected and trained PHC, and control group will include post AMI patients discharged from hospital Cardiology and who do not belong to the selected PHC. The investigation group [constituted by 1 patient that had 2 AMI (2016 and 2019),1 nurse from each CHUC cardiology, 1 nurse from PHC, 2 CHUC Cardiologists, 1 general practitioner, 1 hospital pharmacist and 1 PHC pharmacist], has meets monthly to define strategies to optimize existing health resources to improve the quality of care for citizens with AMI. After implementing the strategies, evaluations are carried out and the strategies are readapted if necessary. Cardiac integrated care intends to improve therapeutic self-care, cardiovascular risk factors management and public healthcare satisfaction in patients with AMI, through integrated care approaches between hospital and PHC .