出版社：Utrecht University, Maastricht University, Groningen University
摘要：It is well known in the literature how the modern health and care systems are being oriented to launch and develop national strategies to construct and build a more comprehensive system for the people with "complex health and social care needs". Most of Chronic Care programs have been introduced proactive care management for this vulnerable population who are causing high utilization of high cost services. However a new Integrated health and social care approach have been introduced in some countries and regions and there is a need of identifying these populations at risk with new and well accepted criteria and new care approaches in the field. This workshop will combine both the "policy and implementation in practice" related to proactive management of people with complex care needs from a joint health and social care perspective. 2 or 3 countries will be invited to explain main strategies and real implementation examples which could be easily escalated. An additional overview of Walter Wodchis as international expert and reviewer of different international national or regional best practices will be incorporated. We will introduce different issues related to complexity: - Earlier work of complex chronic health needs during implementation of Chronic Care programs. Some part of this work has started some time ago and experience of some yers could be - Evolution from the “complex health needs” toward a “complex health and social care needs” approach. New approaches to identify criteria related to complex social care needs will be explored especially related to the social care area. ·International overview of the most recognized innovative experience related to care for people with complex health and social care needs - "Terminology" required to talk properly about "complexity": complexity, complex care needs, multimorbidity, complex health and social care needs,...? - Complex care in practice approach explaining which strategy is being developed to take care of people with complex health and social care needs from an “individual, team and territorial (county)” perspective - ICT developments to support work with different organizations and professionals who work collaboratively to manage people under a "person centred model": introduction of Key Information Summary or Individual Intervention Plans to be shared by all organizations and professionals under a 24/7 scheme and other strategies - Evaluation approach of complex care strategy It would be introduced 2 or maybe 3 experiences and an additional international overview: - Catalonia and Scotland will talk about both policy and implementation in practice models which have priorised "complex care approach" - Walter Wodchis from Intitit oof Healt Policy, Management and Evaluation at University of Toronto speak about the most promising and innovative world experiences related to complex care (Walter Wodchis is co-author of the June issue of IJIC publishing 7 study cases related to complexity), showing lessons about these experiences and reccommendations for countries and regions developing and implementing Integrated Care for people with complex health and social care needs. This workshop will offer a combination of policy and implementation in practice issues and additionally an overview of the best practices in the world related to complex care
