PCC/MACA /Geriatrics (Severe chronic patients/Advanced chronic disease/Geriatrics)
- 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.