标题：Metropolitana Nord community based integrated care programme to people with complex chronic conditions (Programa ProPCC): an experience of integration at meso level in Catalonia
出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : The growing numbers of People with Complex Chronic Conditions (PCCC) has been leading to a challenge of adaptation of the care providers’ response to the high needs presented by individuals. Short description of practice change implemented : The creation of a Chronic Care Management Team (CCMT) supported an innovative strategy focused on reaching a more integrated model of care. A community-based care programme was developed based on: a. International evidence (reviewed by two CCMT experts); b. A consensus reached by clinical leaders involved on care (in a local task force group with 60 members from primary and secondary care); c. The inclusion of people experience (by two focus groups with patients, and home interviews to carers and members of community institutions). It led to a new organisational and governance model for the whole territory. An IT tools adaptation was required to support the CCMT task on monitoring the care process and outcome indicators. Aim and theory of change : In order to improve the quality of the care process and to obtain patient-centred outcomes in an efficient way, it was urged to change the usual model, to a new multidisciplinary, multidimensional, patient-centred provision of integrated care focused in the community, with the central role of expert Primary Care teams. Targeted population and stakeholders : PCCC including those with advanced illnesses. Stakeholders: several units from the Catalan Health Institute in Badalona area, North of Barcelona, as a territorial public provider of primary care and hospital care, which collaborate with other social care and intermediate care providers in the area. Timeline : Phase 1: development of theory for change (2018); Phase 2: implementation of the new model of care (2018-2019); Phase 3: evaluation of the model (2019). Highlights (innovation, Impact and outcomes) People-centred integrated care ongoing project at meso level as a response to high needs of PCCC in an urban territory in the Catalan public health system. Definition of the care model by people involved on care (patients, carers and staff). Functional integration of clinicians from the institution. CCMT led the integration by: defining and monitoring the quality of the care process, planning the adaptation of resources, and evaluating people-centred outcomes. Comments on sustainability: High sustainability expected due to the pragmatic approach. Comments on transferability: High transferability expected due to the position of our institution in the health system. Conclusions (comprising key findings) : Our project was created based on a need to deepen on integrated care provision. Preliminary results on the quality of the care process have been evaluated. Preliminary results centred on people have been evaluated. Discussion : It is a huge opportunity for our system to develop and evaluate an integrated care strategy at a meso level, following the Catalan Government integrated care strategy. Lessons learned : Adapting the theoretical model to real world required a strong leadership, clear governance, time for change and the alignment of all the actors. The consensus reached, based on people experience and views, was a strong element for change.
关键词：people-centred services ; complex chronic conditions ; people ́s experience ; community care
