出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : A Complex Chronic Disease is a condition involving multiple morbidities that requires the attention of multiple health care providers and at home. Complex chronic patients (CCPs) presents unique healthcare needs. Almost 250000 CCPs have been identified within the Andalusian Public Health System (APHS) in 2018. 4% of very complex patients consume up to 30% of primary care and hospitals resources. Policy context : The APHS is responsible for the provision of healthcare and public health services to the entire Andalusian population (8.5 million inhabitants). It is a wide network based on a high-quality, patient-centered, accessible healthcare system with over 1500 primary healthcare centers (PHC) and 49 hospitals, spread throughout the territory. To best tackle CCPs health needs, the “Comprehensive Healthcare Plan for Patients with Chronic Diseases” (CHPPCD) was launched in 2012, aiming to ensure the comprehensive care with a multidisciplinary response to patient needs. The Integrated Care Process ‘Healthcare for Multimorbidity Patients’ was also developed, including all processes and activities, ensuring the comprehensive care of CCPs through the coordination of professional services and/or centers over time, and aiming to decrease clinical variability and improve quality of care received by these patients. Highlights : Since 2016 “Personalized Action Plans” (PAPs) were introduced as key-elements to provide an holistic care, including: taking patient’s individual needs, preferences and own resources as a starting point for their evaluation and the development their PAPs. involving of patient’s informal caregivers in the care process; involving all relevant care levels and health disciplines in the care process ensuring the coordination of the multidisciplinary care and care levels. Thus, and taking advantage of the participation in the EU Joint Action Chrodis-Plus (“Implementing good practices for chronic diseases”, GA 761307), the real influence of the systematized application of PAPs to Andalusian CCPs will be assessed. The pilot, that will be implemented in PHCs of the Andalusian Health Service (the first level access of citizens to and the backbone of the APHS), will bring the first assessment on real outcomes of the systematized PAPs implementation at population level. Comments and conclusions : The participation in the EU Joint Actions is an excellent opportunity to assess and promote the implementation of successfully policies and practices. Patient-centred healthcare approach is best way to tackle CCPs health needs. CHPPCD is a strategic initiative for matching CCPs health needs and expectations with policies, services and resource distribution. Join Actions are EU initiatives that brings added value to local initiatives by boosting cross-country collaboration. Only few integrated care programs for multimorbidity are currently being implemented (most of them tested in small populations), and related literature is scarce. Consequently, the Andalusian pilot within the framework of the Joint Action Chrodis-Plus will assess the PAP implementation outcomes in real conditions and at population level.
关键词：primary healthcare ; chrodisplus ; personalised action plan ; integrated care
