出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : The establishment of a common language and the start up of the future clinical and social shared record has emerged as priorities in Health and Social (H&S) care strategy for Euskadi 2013-2016. After assessing different European tools, it has been chosen InterRAI-CA. The implementation of InterRAI-CA has taken place thanks to a research project funded by Etorbizi, which outcomes (presented in 2014), shows that this is a powerful and effective tool for the development of a common H&S language. This tool also allows obtaining products shared by both healthcare areas: health and social. This instrument has been presented as an interagency project to the Health and Social Care Basque Council as the embryo of a future project of the clinical and social shared records, based on its capabilities to gather H&S common and proven information and to develop individualized care plans. Short description of the practice : The deployment of the tool has an interagency and multidisciplinary scope: 70 users distributed among the three Basque Foral institutions (provincial councils), primary care centers, hospitals emergency, and municipalities of the 3 provinces. It has been realized training session to the professionals involved (doctors, nurses and social workers). Additionally, there are RAI tutors who have been appointed in each organization to facilitate the implementation and use of the tool. The RAI assessment applies when the H&S care professional detects a case of H&S intervention, preferably in regards to the group of elderly people in a situation of dependency. The result will be contrasted systematically between H&S primary care teams (sent by email). The result of the assessment includes the H&S diagnosis and the first Individualized Care Plan. Finally, the H&S team should meet to validate or improve the care plan and, after that to review and follow-up the case. Goals : • To promote the presence of interoperability tools in the health and social context.
关键词：common language ; clinical and social shared record ; interagency project ; h&s primary care teams ; h&s care plans ; dependency
