Unidad de Continuidad Asistencial (UCA)


Hoy nos dedicaremos a hablar sobre la Unidad de Continuidad Asistencial (UCA), explicaremos qué es, a qué se dedica y qué beneficios se aportan a los pacientes desde este servicio. 
 ¿En qué consiste esta unidad?
Es una unidad que recibe a pacientes que nosotros llamamos “Crónicos Pluripatológicos  G3” es decir, pacientes que padecen varias patologías crónicas y que a causa de ellas, sufren frecuentes descompensaciones e ingresos en el hospital.
Tras el diagnóstico de una condición crónica de salud, comienza un proceso de atención que precisa estar bien planificado y organizado para atender tanto las necesidades de los pacientes como la atención a las personas cuidadoras, de acuerdo a unos determinados estándares de calidad y evitando la fragmentación de los cuidados, principalmente en situaciones de cambio de nivel asistencial.
Es importante intentar evitar en la medida de lo posible el ingreso del paciente. La hospitalización va asociada con frecuencia a una pérdida funcional y de independencia del paciente y, por tanto, a una pérdida en su calidad de vida. Si se evita o disminuye la estancia en el hospital se reducirá, además, el riesgo de eventos adversos asociados a la hospitalización.
Pese a que el ámbito operativo del Proceso de Atención al Paciente Crónico Pluripatológico es la atención primaria, por su mayor grado de  proximidad y más facilidad de acceso entre otras cosas,  la gestión de los pacientes deberá ser compartida con la atención hospitalaria, especialmente para aquellos pacientes pluripatológicos de mayor complejidad, cuya entrada en este nivel asistencial se realizará fundamentalmente a través de las denominadas Unidades de Continuidad Asistencial (UCA), que facilitarán un acceso y una gestión ágil de los pacientes entre los dos niveles asistenciales, proporcionando los cuidados adecuados a sus necesidades y al nivel de progreso de su enfermedad.
Por decirlo de alguna manera, la UCA actúa como puente entre atención primaria y atención hospitalaria, disminuyendo el número de ingresos, evitando la saturación y larga espera de las urgencias, proporcionando tratamiento y garantizando en todo momento la continuidad de la atención (seguimiento por su médico y enfermera de atención primaria en estrecha relación con los profesionales de referencia en el hospital) del paciente crónico pluripatológico.
¿Qué se hace en la UCA principalmente?
En función de la valoración clínica, y teniendo en cuenta los recursos disponibles en la UCA y en el Hospital, se podrá proponer la:

  • Modificación de la pauta de tratamiento
  • Realización de procedimientos terapéuticos en la propia consulta o en hospital de día
  • Hospitalización en camas de UCA/Medicina Interna
  • Solicitud de pruebas complementarias y/o interconsulta con otros servicios
  • Hospitalización en otros servicios del hospital

¿Qué garantiza entonces la UCA?  La UCA garantiza:

  1. Continuidad de atención, ya que se trabaja en estrecha colaboración atención primaria y atención hospitalaria.
  2. Accesibilidad, tras una detección temprana de una descompensación.
  3. Rapidez de respuesta, cuando sea necesario realizar pruebas diagnósticas o terapéuticas en la unidad UCA, evitando que tenga que acudir a urgencias o sufrir demoras y esperas.
  4. Atención integral y personalizada de todos sus problemas de salud.

 ¿Qué es necesario conocer antes de acudir a la consulta UCA?

  • Hay tres formas de acceder a la unidad
    1. Derivación desde el médico o la enfermera de atención primaria. A través de la comunicación telefónica entre los profesionales de atención primaria y los profesionales de la UCA.
    2. Interconsultas de otros especialistas del hospital
    3. Excepcionalmente, remitidos desde urgencias. Como hemos dicho, con la UCA se pretende que el paciente sólo acuda a urgencias en el caso de que la descompensación ocurra fuera del horario de funcionamiento de la misma.
  • Cuando el paciente sea derivado a la consulta UCA debe aportar:
    1. Toda la documentación que disponga sobre antecedentes personales, alergias y sobre el proceso actual que le ha hecho acudir al hospital.
    2. Hoja actualizada con la medicación que está tomando actualmente. Tipo de medicamento, dosis y hora de administración.
    3. Consultas externas pendientes citadas en el hospital para otras especialidades.
  • El tiempo de estancia en la unidad será variable, dependiendo de las pruebas diagnosticas y terapéuticas que el paciente precise.
  • No es necesario acudir en ayunas a no ser que previamente se le haya comunicado.
  • Cuando no sea posible solucionar en el mismo día el problema de salud por el que se le ha derivado al hospital, se trasladará a la Unidad de hospitalización de la UCA, siempre y cuando la estancia prevista sea inferior a 48-72 horas. Si transcurridas esas 48-72 horas no se ha estabilizado el paciente, se ingresará en el servicio de Medicina Interna hasta que su patología se resuelva.

Nerea García Granja
Enfermera residente, EFyC, C. S. La Victoria, Valladolid

 
 
REFERENCIAS:

  • Grupo de Trabajo de la Sociedad Española de Medicina Interna (SEMI) y la Sociedad Española de Medicina Familiar y Comunitaria (semFYC). Documento de consenso atención al paciente con en- fermedades crónicas. 2011. Disponible en: www.opimec.org/…/declaracion-de-sevilla-atencion-al- paciente-con-enfermedades-cronicas/
  • Junta de Castilla y León. Estrategia de Atención al Paciente Crónico en Castilla y León. Valladolid: Junta de Castilla y León, Consejería de Sanidad, Gerencia Regional de Salud de Castilla y León; 2013.
  • Ley 39/2006, de 14 de diciembre, de Promoción de la Autonomía Personal y Atención a las Perso- nas en Situación de Dependencia.
  • Ley 16/2003, de 28 de mayo, de Cohesión y Calidad del SNS.
  • Ministerio de Sanidad, Servicios Sociales e Igualdad. Estrategia para el Abordaje de la Cronicidad en el Sistema Nacional de Salud.
  • Sociedad Española de Medicina Interna (SEMI), Sociedad Española de Medicina de Familia y Co- munitaria (semFYC) y Federación de Asociaciones de Enfermería Comunitaria y Atención Primaria (FAECAP). Desarrollo de guías de práctica clínica en pacientes con comorbilidad y pluripatología. Madrid: SEMI, semFYC y FAECAP; 2013.

 
Revisado: enero 2018

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