Orientation and experience in a system of integrated care in a European Region: Castilla y León

Abstract

Introduction : Models and foundations to make possible the integrated care and socio-sanitary coordination In Europe (and in other Western countries: USA, Canada, Australia, etc.) There are different initiatives seeking an integrated health, and tangentially with social services care. This movement is associated with how to meet the chronicity and aging from a preventive perspective, focused on health care and improvement of care for activities of daily living. But only developing structural elements for the coordination is not enough to make possible an integrated care, defining processes of care tailored to specific situations of need for integrated care is needed. But as a first step, there are different situations and elements to manage: access to the services of each system, the territorial organization, the imbalance in relations between the health system and social services, the absence of common information about users, etc. Description of the policy : current approach of coordinating healthcare in Castilla y Leon The health and social care coordination strategy in Castilla y Leon seeks to organize integrated care based on situations of need and defining actions to provide professionals in each one of the systems, with simultaneous or sequential tasks, depending on the need: developing processes. Organizations must to start from a joint analysis of the situations of need and the search for user profiles. Organizations must to develop a proactive orientation of health and social services, adapting the attention to the real needs of the people. Organizations must to focus on the proximity care, with community-level professionals (teams) who manage each case (case handlers working together in health and social systems), and where appropriate, by specialized professionals (in both systems). Care will be provided with a person-centered approach. Processes and services must be able to provide and manage the continuum of care, trying to develop the care at the community level and promoting greater coordination between health and social professionals. For better results on integrated care, empowering the social system is needed. Key findings and discussion : from orientation by structures towards process orientation The route started in Castilla y Leon for the integrated is focused on developing processes that achieved the integration of systems within the final care. Some examples: Integrated processes: processes implemented Convalescence socio-sanitary units: persons in situations of dependency for the ABVD as a result of processes of chronic disease or diseases usually associated with aging, stabilized, but that due to an acute process or to a decompensation of chronic processes with lack of self-sufficiency, in need of health care and nursing during the convalescence period, as well as social care associated with their lack of autonomy. Integrated care to people with mental illness: continuity of health and social care to people disabled by mental illness through the coordination and development of specific resources by the health and social services systems working together. Early attention: coordination of health, social services and education systems focused on the needs of the child, their family and environment by a unique team of early intervention, the active participation of families, the derivation between systems and the evaluation of the quality of the services. Integrated processes: processes in development Technology platform for integrated care: is a technological solution (software), for integrating the information and data of health and social systems, enabling telehealth and social care to improve the health and social care processes for keeping the people in their homes. Integrated home care: set the mechanisms of access, coordination and follow-up for the improvement of users and their caregivers’ guidance. Conclusion : Despite the common elements for the approach of integrated care, each Region must organize themselves, taking into account their systems configuration and prior organizational development and the characteristics of its territory, in a flexible way to be able to generate a care system. The Castilla y Leon model can provide information relevant to other regions with a strong aging and low population density.