Challenges and achievements in integrated care: different health and social care providers working together. Successful projects that show that this is the way

摘要

Background : The Catalan health system is a public healthcare system, funded by taxes, with universal coverage and public healthcare services portfolio. There’s a mixed healthcare providers network. On the other hand, there’s a public network of social services also focused to chronically ill patients social needs. Delivery of integrated health and social care with a shift to a patient-centered model is one of the main challenges of our public system. We will share three experiences of different models developed to improve integration of social and healthcare services, to guarantee the continuum of care and to achieve quality health and social care outcomes. Projects : 1.- Chronicity and the role of nursing expertise: care and cure network. N Borrell, Clinical Nurse Complex Surgical Patient, Moisès Broggi Hospital. Chronic patients care is one of the challenges of the health system due to increasing incidence and morbidity of population involved. To meet the complex chronic patients (PCC) needs or advanced chronic illness (MACA) we have developed Integrated Care Units (AAI) led by nurses as responsible for ensuring a comprehensive and integrated nursing care, ensuring quality of care and continuum between health and social services. Results show that people needs are better identified and care resources better used. 2.- Integrated care model: a framework for collaboration between Social and Healthcare for home care of dependent people. JL Argudo, Director of Healthcare Programs, Parc Sanitari Sant Joan de Déu. A Pérez, director Fundació d'Atenció a la Dependència Sant Joan de Déu. This initiative was launched to assist people at home, both to solve social issues as dependency or autonomy improvement as well as healthcare needs, and is based on public-private co-operation between different health and social care institutions. Among its strengths includes cooperative work to detect user's needs before discharge from hospital, professionalized care and coordination between health and social teams. 3.- PRINCEP program: clinical program for specialized and integrated care of pediatric patients with complex chronic conditions. N Ricart. PRINCEP program. Pediatrics Department. Hospital Sant Joan de Déu, Esplugues, Barcelona (Spain) With the development of the science and technology applied to health, infant mortality has drastically dropped in the last half century. This longer survival has led to a new phenomenon: the increase in pediatric complex chronic conditions (CCC). PRINCEP program is aimed to offer integrated care for patients who are dependent of technology assistance, need specific case management or regular use of hospital facilities. The program is efficient in the care of CCC children with social vulnerability. Results shown that its implementation to other areas would allow better care coordination and savings in health and social costs. It also obtains long-term benefits for the health system: a greater number of CCC children will reach the adulthood in better conditions, being well integrated in its community and well known for the professionals, allowing the optimization of resources and the patients well-being.