Catalonia (Spain)

Region:

Osona

Target group:

Severe chronic patients, advanced chronic patients and people > 85 years old

This is a hospital-based integrated care programme at the population level in which different care levels are coordinated (primary care, acute care, intermediate and long-term care). The specialized care including the acute care (Vic Hospital Consortium), the intermediate care and long-term care (Santa Creu Foundation) have redesigned and reorganised their service delivery model under common agreements. Social care is provided from the different care levels and it is well articulated with social services at the City Council level, which manages more legal aspects (dependence law). All patients have a comprehensive assessment resulting in an individualized intervention care plan agreed with the patient and the family.

Region:

Vallès Occidental

Target group:

People with multiple social and health care needs. Eligibility criteria were jointly defined by social and health care professionals and they help to identify the target population. (e.g., chronic diseases, complex pharmacological treatments, lack of main caregiver, unskilled caregiver, among others)

This is a primary care based integrated care initiative in coordination with social services. This initiative is carried out in three Primary Care Centres (PCC Nord, PPC Ca N’Oriac and PPC Concòrdia) from which both health and social care are provided to the population living at the northern area of the city. Integration results from health and social care professionals sharing an agenda in which eligible cases are signed up to be discussed on a monthly basis meetings. Care plans are designed in these meetings and agreed with patients and family.