From care in clinically complex cases to a model of integrated health and social care

Introduction:The Program of Chronic Complex Patient of the Alt Peneds (PCCPAP) faces the challenge of improving the quality of care to this patient profile.It determine collaborative and proactive care strategies, which are directed at adapting the use of the health and social care resources.Location:The Health District of the Alt Peneds (Catalonia-Spain) has a population of 97.000 inhabitants and several health and social service providers.In 2010, the health care of CCP was fragmented, with a recurrent and high-frequency use of health emergency, hospital and community service.It was a determining factor to prioritize the health care to Heart Failure (HF) and Chronic Obstructive Pulmonary Disease (COPD) patients.Objectives:To provide integrated health care to CCP in community environment, promoting maximum autonomy within the individual situation of complexity and dependence.Identification of population target and organizations implied (stakeholders):Initially CCP were identified through a predictive model of hospital re-admissions.At the present time the classification system used is Clinical Risk Group (CRG): CRG 6 to 9 with hospital admissions and long term-care during the last year.Along side the clinical criterion of the health care professionals.PCCPAP is integrated by the three suppliers of health care of the territory (Primary Care, Hospital and Long-term care) and two providers of social services

Health care · Integrated care · Political science · Social care · Chronic Disease Management Strategies · Healthcare Systems and Practices · Healthcare Systems and Technology · Medicine · Nursing