Summary: Palliative care has traditionally been at the forefront in coordinating specialised services with primary care and home care. Health care staff work in interdisciplinary teams, using empathy as the basis for analyzing the needs of patients and their families, from a holistic and integrated perspective.In the context of the new paradigm of people-centred integrated care models, true integrated care in palliative care is linked to two key elements: the coordination of health and social services in end of life care and the involvement of society through awareness and training of community networks. The first requires a change in the organizational model and the second needs a basic refocusing on training of professionals.A number of international experiences are showing the way, proving compassionate social care models which empower families and carers and align professionals and resources to provide high-quality integrated care to end-of-life patients. Which are these? What can we learn from them? What trends can be identified in palliative integrated care?
Summary: This study aims to analyse and define the role of the case manager (CM) in Spain. The qualitative technique of semi-structured interviews together with the literature review technique have been chosen for the information gathering process. This study constitutes the first of the several stages of a broader research project whose ultimate goals are to create a Network of Integrated Care professionals (NIC) and to reach some conclusions about the CM role in Spain.The rise of chronic diseases, partly caused by demographic changes and increased longevity, requires the development of new strategies on health and social care policies. High levels of dependency associated to chronic patients imply that health care and social problems need to be addressed through coordinated actions of these two public services. The implementation of the CM seek to respond to this need.CM for chronic patients usually undertake coordination tasks within different levels of the health care system and between the health care and social systems. This coordination substantially enhances the continuity of care. Case management enables the integration of the social and health care systems and, therefore, the integrated and needs-centered health care service that patients require.The definition of the role played by the CMs is highly ambiguous; pluripathologies management, single collective (fragile elderly) and single disease management, to name only a few, are amongst them. Nevertheless, there have been also identified some of the CM most basic elements including; patients identification, problems and need assessments, care plan setting, etc.Methodology: Through the usage of an explorative methodology, the numerous roles played by the CM in Spain will be identified and classified. More concretely we will be looking at the main similarities and differences, and analysing impact results. Ultimately patterns and potential scenarios will be considered. This methodology is composed by various stages; 1-Semi-structured interviews and literature review techniques will be used to gather information from professional interviewees (professional profiles, services offered, population target, etc). In addition, a theoretical framework will support the information provided by these professionals.
Organisational innovation: the method facilitates strategies and tools for transforming organisations through change management; it changes the insurer-provider relationships by introducing new financial mechanisms; etc. Societal innovation: compassion is the key. Comments on sustainability: Upon completion of the process, the host organization is left with systems in place to maintain its integration efforts, strengthen its internal and external relationships, monitor key indicators and promote staff involvement and open communication. Comments on Transferability: The method is a tool to help organisations transform towards the delivery of the best possible care: thus, it aims to be transferred to other settings and policy contexts. Conclusions and lessons learned: NEWCARE© is already being implemented in a Colombian health insurance organisation with a focus on patients with chronic organ failure (Newcare-IOCC by its initials in Spanish, Insuficiencia Orgánica Crónica Compleja). At the conference, we will share insights of how this organisation is progressing, its preliminary results and which challenges as well as enablers are being encountered.
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