出版社：Utrecht University, Maastricht University, Groningen University
摘要：Background : Care models for advanced chronic patients present two key aspects: early identification and advanced care planning (ACP). In 2014, Catalonia arranged the ACP Model (ACPM), addressed to chronic patient’s complex needs, into a public health-social system (HSS). Aims : Describe the implementation process (IP) of an ACPM. Methods : A core group of professionals (n=55) was convened to develop the ACPM with the co-participation of patients, caregivers, social agents and healthy persons. Inclusion criteria included: solid professional trajectory, equal representation as for territory and professional profile. Four work levels were defined: conceptual document (CD) and implementation guide (IG) elaboration; training program (ITP) development; building-up of patients, professionals and healthy persons discussion groups (DG). The CD and IG were written with the agreement of expert professionals in legislation, ethics, medical specialities, nursing, anthropology, social work and psychology. The ITP is being created, as a key aspect of the IP. Results : CD and IG have been published. Simultaneously, DGs are established so as to make the CD a work product of high quality. The ITP is currently being developed, based on CD and IG contents. These documents have been reviewed by around 100 professionals from the Catalan HSS. The ITP contents focus on communication skills; legal and ethical aspects; patient and family needs. Discussion : ACP is a challenge for the model of care towards advanced chronic patients. Conclusions : ACP is a challenge for the model of care towards advanced chronic patients. The Catalan Model of ACP establishes the conceptual and pragmatic foundations of ACP and develops the training of the professionals daily taking care of such type of patients.
关键词：advance care planning ; person-centred care ; integrated care ; decision-making process ; chronic advanced diseases
