标题：Inter-professional coordination: first step towards a more person-centred approach. Improvement projects in Catalonia within the framework of the SUSTAIN project
出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Established integrated care initiatives around Europe are working within the framework of SUSTAIN project to improve their current practice in four domains: patient centeredness, prevention, efficiency and safety. In Catalonia these initiatives are: 1) PCC/MACA/Geriatrics a regional-level initiative aiming at providing coordinated and integrated care between different health care levels with Social Services from different County Councils in Osona 2) Social and Health Care Integration of Sabadell, seeks for the coordination between three Primary Care Teams with Basic Social Services from Sabadell City Council to provide integrated care to patients with health and social care complexities. Both initiatives have identified barriers for professional coordination and integration, as well as the need of working with a more patient-centred approach Short description of practice change implemented : In both sites similar interventions will be implemented during 18 months, entailing a multidimensional assessment of selected older people (cases) with complex health and social care needs performed in inter-professional meetings with a tailor designed tool. Afterwards, an individualized interview with older people to validate this assessment and to develop a joint care plan for health and social care professionals involved including goals, views and opinions of the cases. From this full written care plan, key information will be selected following a manual specifically developed by the Steering Group members to be included in the Electronic Care Plan (i.e., PIIC) which is shared through the Electronic Medical Record among all health professionals in Catalonia Aim and theory of change : The aim is to improve professional coordination in the delivery of health and social care and to enhance patient’s empowerment by involving them in the development of joint care plans. This process is underpinned by the Evidence Integration Triangle, an approach targeted at effective implementation of scientific evidence in daily practice Targeted population and stakeholders : Patients with multiple health and social care needs older than 65 living at home and cognitively able to participate Main stakeholders are health and social care professionals with different degrees of responsibility in decision making Timeline : Between October 2016 and April 2017 each site will conduct a pilot implementing the intervention with 6 patients. The improvement project will be then rolled out for 12 months including 36 patients in each initiative Highlights: (innovation, Impact and outcomes) Innovations: - The incorporation of the patient in setting a joint care plan - A tailor designed tool for performing joint multidimensional assessments Impacts: - A progressive acknowledgement from health and social professionals of the importance of discussing complex cases in inter-professional meetings and of the benefits of working in a more integrated way - Increasing patient’s empowerment and improving knowledge and perception about the coordination of the care they receive Outcomes: - Full care plans with the inclusion of patient’s opinions, views and beliefs - Key patient-centred information shared in the Electronic Care Plan (PIIC) with all health professionals Comments on sustainability : Both SUSTAIN improvement projects are aligned with the roadmap set by the Inter-departmental Plan of Social and Health Care and Interaction launched in 2014 by the Catalan Government to impulse change towards a more integrated way of working in the country Comments on transferability : Both tailor designed tools can be transferred to other initiatives to assess patients with complex health and social needs
关键词：inter-professional coordination ; multidimensional assessment ; care plans ; patient-centredness ; local case studies
