Designing a Person-Centred Integrated Care Programme for People with Complex Chronic Conditions: A Case Study from Catalonia
Miquel Àngel Mas, Ramón Miralles, Consol Heras, María Ulldemolins, Josep Maria Bonet, Núria Prat, Mar Isnard, Sara Pablo, Sara Rodoreda Noguerola, Joaquim Verdaguer, Magdalena Lladó, Eduard Moreno‐Gabriel, Agustín Urrútia, Maria A. Rocabayera, Nemesio Moreno-Millan, Josep María Mòdol, Isabel García Andrés, Oriol Estrada, Jordi Ara del Rey, ProPCC-Badalona Group*
Abstract
INTRODUCTION: The prevalence of people with complex chronic conditions is increasing. This population's high social and health needs require person-centred integrated approaches to care. METHODS: To collect data about experiences with the health system and identify priorities for care, we conducted 2 focus groups and 15 semi-structured interviews involving patients with multimorbidity and advanced conditions, caregivers, and representatives of patients' associations. To design the programme, we combined this information with evidence-based recommendations from local healthcare and social care professionals. RESULTS: Patients' and caregivers' main priorities were to ensure (a) comprehension of information provided by healthcare professionals; (b) coordination between patients, caregivers, and professionals; (c) access to social services; (d) support to caregivers in managing situations; (e) perceived support throughout the healthcare process; (f) home care, when available; and (d) a patient-centred approach. These dimensions were included in 37 of 63 clinical actions of the programme to cover the whole care trajectory: identifying high needs, defining, and providing care plans, managing crises, and providing transitional care and end-of-life care. CONCLUSION: We developed an evidence-based integrated care programme tailored to high-need patients combining input from patients, caregivers, and healthcare and social care professionals.