We found a match
Your institution may have access to this item. Find your institution then sign in to continue.
- Title
The development of a successful integrated care model.
- Authors
González González, Ana Isabel; Miquel Gómez, Ana María; Morales, David Rodríguez; Sierra, Victoria Benavides; Romero, Andrés López; Rodilla, Juana Mateos
- Abstract
Introduction: In order to achieve a successful integrated model, organizations must work in the development of six key elements that have been extensively described in the literature: coordination between policy makers and managers at regional and local levels; single entry to social and health care services; case management; individual care plan; autonomy functional assessment instrument; and shared electronic health record. The establishment of these mechanisms and tools enables the integration of different services and the implementation of an unique model of action, due to the participation and coordination of all those involved in it. Description of the policy, its objectives and targeted population: The Strategy for the Care of Patients with Chronic Diseases in the Madrid Region is developing an innovative model of integrated care aimed at people with multimorbidity and complex needs which objective is tofacilitate access to health and social care. Despite the development of regulatory and structural elements that can be more complex to achieve, the functional development of health integration models that have shown positive results guide and is guiding our actions. Key findings: The implementation of the Strategy in the Madrid Region is already a fact and involves shifting the Kaiser Permanente and the Kings Fund models to our reality, and therefore the adaptation of health and social systems to the needs of each patient. One of its lines of implementation includes the development of the necessary elements for enhancing the social and health coordination thus: identifying all cases and recording them in an unique registry; developing an integrated care pathway for patients with complex social and health needs; implementing the nurse case manager role; shared electronic health record; enhancing primary care centers as the patient managers and coordinators of the social and health resources; and the evaluation, progressing in obtaining results in health and social dimensions. All these projects are nowadays rapidly progressing and developing. A Social and Health Commission was created for the accomplishment of all these goals and several working groups have been established and are steadily progressing. In addition, there are already four experiences that carry some of the six key elements to our reality at the local level or towards some specific types of patients such as: the Coordination Plan for Social and Health Care for the Fragile Elderly; the Social and Mental Health Coordination Project for adults between 18 and 65 years with severe and chronic mental disorder, psychosocial disabilities and difficulty of integration; the Coordination Protocol between Hospital Emergency Units and Nursing Homes; and the Social and Health Care Coordination Model between Madrid Health Service and the Regional Service of Welfare. Highlights: While there are mechanisms that could cost more like high-level coordination that involves conducting legislative and structural changes, both functional coordination and the development of other elements are feasible. Conclusion: Many of the proposed elements are transposable to our and other models of care. In the Madrid Region, we are currently working aligned, existing local experiences and progress in this regard.
- Subjects
HEALTH policy; HOSPITAL case management services; MEDICAL care; ELECTRONIC health records
- Publication
International Journal of Integrated Care (IJIC), 2015, Vol 15, p158
- ISSN
1568-4156
- Publication type
Article