Metropolitana Nord community based integrated care programme to people with complex chronic conditions (Programa ProPCC): an experience of integration at meso level in Catalonia

Abstract

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). conditions (Programa ProPCC): an experience of integration at meso level in Catalonia 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.

Evaluating Person-Centred Integrated Care to People with Complex Chronic Conditions: Early Implementation Results of the ProPCC Programme

“…In Catalonia, the Metropolitana Nord Chronic Care Management Team at Institut Català de la Salut (Catalan Health Institute), the main health public provider in our region, has developed a strategy to improve the quality of care to chronic complex patients and patients with advanced illness. They developed an innovative care model that emerged from the Community Based Integrated Care Programme for People with Complex Chronic Conditions (ProPCC Programme) [8][9]. The theoretical frame of our project can be found in a previous publication in this journal [10].…”