出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : In the last decade , the focus of the health care have slowly shifted from the acute care to the care of the chronic conditions . Several documents from the WHO indicated the path to a new paradigm of care . Significantly in 2008 the WHO Europe , has published “ How can chronic disease management programmes operate a cross care settings and providers? “In this document the mental Health problems , addiction condicions intellectual disabilities , brain injuries and mental health problems beguining at childhood ages have been taken in account. For decades , the mental health sector have been dealing with mental chronic conditions and developed programs and resources to manage the evolution of the mentioned conditions. The concept of Severe Mental illness has , actually , been loosing the significance to identify the complexity of the people who is attended in the Mental Health System , because the increase of comorbidities : physical chronic conditions , use and abuse of substances , mental health problems beguinning at childhood , intellectual disabilities , behaviour diseases ,.. , so a wide concept of SMD is need to be developed . Objective : To aligne the Mental Health chronic conditions inside the same stratification method for the physical chronic conditions ; we set a criteria to define the Chronic Mental Health Patient ( CMHP ) , a wide criteria for SMD , and Complex Chronic Mental Health Patient ( CCMHP ) : also we develop a 3 Clinical Risk Groups ( groupers ) for the Mental Health conditions , named GMA ( Adjusted Morbidity Groups ) , and we test the consistency and the prediction of needs of the identified people into these criteria. Taking in account social needs and involving the Primary care , welfare network , Hospitals , mental health and addictions network of care at the management and therapeutic plan. Practice implemented : The Catalan Department of Health , through the Mental Health and Addictions Master Plan ( PDSMiA ) and the Chronicity Prevention and Care Program ( PPAC ) has established the use of the Criteria of Chronic Patient ( broader concept of SMD ) and the Criteria for Complex Chronic Patient ; This last concept includes physical comorbities and some social conditions and needs ; after the results obtained by the Analysis Division of the Demand and Activity. Catalan Health Service have accorded to use this taxonomy in the national register system ; At, the moment, following the personal health card for the all Catalan population , we got data from 10.121.939 registered persons of wich 7.610.154 milions cards are from living people ( the Catalan population ) . The robust health registration catalan system is the key to make the results reliables and feasible.
