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.
Highlights
The prevalence of people with complex chronic conditions is increasing
Societal ageing and decreased mortality associated with various conditions due to improved health-system efficiency have led to an increase in the number of frail older people and people with multimorbidity [1]
Various studies show there is a small group of people with complex chronic conditions who are characterized by high health and social needs
Summary
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. Various studies show there is a small group of people with complex chronic conditions (such as multimorbidity, advanced frailty or advanced illness) who are characterized by high health and social needs This population, often referred to as “high-need, high-cost patients” [2], requires a person-centred approach; otherwise, their needs can go unmet when fragmented care fails to cover one or more conditions [3, 4]. Several clinical programmes have been implemented across the territory to develop and assess intervention strategies, following this identification [22]
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