Introduction
The Chronicity Prevention and Care Programme set up by the Health Plan for Catalonia 2011–2015 has been an outstanding and excellent opportunity to create a new integrated care model in Catalonia. People with chronic conditions require major changes and transformation within the current health and social system. The new and gradual context of ageing, increase in the number of chronic diseases and the current fragmented system requires this transformation to be implemented.
Method
The Chronicity Prevention and Care Programme aims to implement actions which drive the current system towards a new scenario where organisations and professionals must work collaboratively. New tools should facilitate this new context- or work-like integrated health information systems, an integrative financing and commissioning scheme and provide a new approach to virtual care by substituting traditional face-to-face care with transfer and shared responsibilities between patients, citizens and health care professionals.
Results
It has been observed some impact reducing the rate of emergency admissions and readmission related to chronic conditions and better outcome related to better chronic disease control. Some initiative like the Catalan Expert Patient Program has obtained good results and an appropriate service utilization.
Discussion
The implementation of a Chronic Care Program show good results but it is expected that the new integrated health and social care agenda could provoke a real change and transformation. Some of the results related to better health outcomes and a decrease in avoidable hospital admissions related to chronic conditions confirm we are on the right track to make our health and social system more sustainable for the decades to come.
Introduction: We are facing a paradigm shift, evolving from a paternalistic model to a deliberative model in which the person-as a patient, relative or carer-takes a protagonist, active, dynamic and directional role, encouraging responsibility, empowerment and shared decisions. In addition, we must consider the tendency to promote a focus on the individual and their environment, which is committed to a partnership between the health and social world and comprehensive care from a population and integrated vision. This change of role implies a link between the community and health systems. In this sense, it has been implemented the Expert Patient Program Catalonia™ (EPPC), an initiative committed to taking responsibility for people with chronic health problems and to promoting self-care. The EPPC is a multidisciplinary initiative based on patient-healthcare professional collaboration and team work. In EPPC, Expert Patient (EP) leads the process and transmits knowledge about their disease to other patients who suffer from the same health problem. The healthcare professional becomes an observer, and only intervenes if it is necessary. The Expert Patient is a
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