Responding to challenges, a model under transformation: integrated care pathway for the patient with multimorbidity and complex needs

Description:
Models of care for patients with multimorbibity and complex needs (MCP) are oriented towards a more comprehensive assistance from the patient's experience that has to be continuous and consistent, ensuring the necessary services in the right place and moment and within the time required, maximizing health outcomes. At Madrid Region, the estimated number of MCP is approximately 87.171 patients.

How to cite:

Perez OM, Gómez AMM. Responding to challenges, a model under transformation: integrated care pathway for the patient with multimorbidity and complex needs / Respondiendo a los desafíos, un modelo en transformación: integrando vías de atención para el paciente con multimorbili. International Journal of Integrated Care. 2015;15(8). Available at: http://www.ijic.org/articles/abstract/2316/

Description of the policy, its objectives and targeted population:

The Strategy for the Care of Patients with Chronic Diseases at Madrid Region has defined the model of care for MCP establishing what activities should be conducted, responsibles, where and when according to scientific evidence. The model responds to the challenges of individualization, management at the ideal setting and by the indicated professional, proactive monitoring, continuous and efficient capacity for resolution, flexible definition of roles and effective communication.

After a comprehensive review of the literature a working group was created to define: what, who, how, registration systems and support. 14 patient organizations and 26 scientific societies of primary and hospital health care contributed as well reviewing the final document.

We are now in the process of implementation and evaluation of its impact on health care costs and experience.
Key Findings: The integrated care pathway (ICP) for the MCP describes the continuing care route that meets the patient's condition at all times defining procedures, responsibilities, roles and tools.

Identification and inclusion in the ICP

Any health or social professional can identify and communicate complex needs to the primary care (PC) professionals by a two-way established circuit.

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