出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction and policy context : In the Valencian Region social services and the healthcare system are not connected. Also there is not any normative jointly regulating resources, services or aid benefits that would mean an integrated care IC portfolio. Primary care PC centres are the closest and most trustworthy care facility for patients in the Spanish context. Also, PC is one of the most suitable resources to address needs of complex patients, as elderly and/or those with chronic conditions, through an IC approach, but there are some barriers that block its real and effective deployment. Objective and target population : Authors have studied the viability, implementation and development of stratification tools at PC as a promoter of IC within the Valencian Healthcare System VHS. On the basis of their work and close interaction with PC multidisciplinary staff and patients, some gaps were detected. So, this paper presents three main policy recommendations that the VHS – and other healthcare systems with similar characteristics – may take into consideration to facilitate the introduction of an IC approach. Highlights and transferability : Implementation of systematized, automatized and computerized stratification strategies at the VHS by including predictive algorithms within electronic health records EHR. Early identification of patients at risk through stratification tools provides useful information to carrying out appropriate preventive and intervention actions aimed at reducing the probability of adverse events at short or medium term. Design of a unique portfolio with health and social care services specifically addressed to complex patients. The connection between health and social care systems is possible by establishing agreements on specific administrative activities between decision-makers from each system. On the basis of this regulation, common action plans and guidelines should be launched including healthcare resources and social services at local level. Multidisciplinary case-management teams at PC centres are a relevant pillar to manage and take decisions regarding complex patients. Moreover, specific training for staff and new functions at EHR should be implemented in order to assure effective coordination and communication flows between these professionals. Strengthening of the role of EHR in the VHS by promoting their correct use by care professionals and raising awareness of electronic records research. Firstly, a unique electronic clinical history system should be available at Spanish level or, at least, interoperability between the different EHR used in each Autonomous Community must be introduced. Moreover, the VHS should promote using electronic records to carry out live, dynamic and smart monitoring of population health and to develop small/large scale predictions of patients’ health outcomes and needs. Conclusions : PC multidisciplinary teams have a fundamental role in the approach of chronic conditions and older people since an IC perspective. New work cultures must be fostered to facilitate the coordination between professionals and the introduction of new technological infrastructures through EHR for an effective exploitation of data available in. Stratification and predictive systems are only an example of the potentiality of electronic records to plan preventive actions, interventions and policies in order to respond challenges that complex population mean.
关键词：primary care ; stratification tools ; complex patients ; electronic health records ; policy recommendations
