This distinction certifies the quality of its processes, continuous improvement, patient safety, and care excellence. The unit comprises four nursing professionals, two from Hospital Care and two from Primary Care, working under a unified organizational model to ensure a safe and effective transition for the most fragile and vulnerable patients between the hospital and primary care health centers.
The work developed by this Unit is part of the Plan 5C (Action Plan for Chronically Complex Patients in the Canary Islands), specifically lines of action three and four, focused on enhancing intra- and inter-institutional care, health, and social coordination, and facilitating health and social care continuity.
The care process is based on multidisciplinary coordination, monitoring both inpatients and outpatients. It focuses on managing complex cases, including elderly individuals with hip fractures, stroke patients, geriatric patients, and individuals with advanced chronic illnesses.
The unit stands out for its close coordination with different care levels and its participation in multidisciplinary hospital teams. It identifies patient needs, establishes individualized care plans, and incorporates the identification, assessment, and training of caregivers to ensure quality care continuity at home.
Specific tools within the electronic health record facilitate the systematic workflow, ensuring all involved professionals have real-time access to the necessary clinical and care information for coordinated, safe, and continuous care for patients and their caregivers.
During 2025, the unit managed 1,834 cases, a 21.77 percent increase compared to the previous year, and conducted 4,099 follow-ups. Over 95 percent of the managed patients did not require hospital readmission within thirty days of discharge.
These results highlight the impact of a care model based on multidisciplinary coordination, discharge planning, and continuity of care. The unit has consistently adapted to the needs of patients and the healthcare system, undertaking significant interventions during the COVID-19 pandemic, in the care continuity of undocumented migrant patients, and in managing chronically complex patients.
Achieving the ISO 9001:2015 certification recognizes over two decades of work and establishes the Continuity of Care Unit of Hospital La Candelaria and the Primary Care Management of Tenerife as a benchmark in care coordination within the Canary Islands Health Service.
