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Review
. 2017 Jul 14;27(1):44.
doi: 10.1038/s41533-017-0043-9.

Protocol for regional implementation of community-based collaborative management of complex chronic patients

Isaac Cano  1   2 , Ivan Dueñas-Espín  3   4 , Carme Hernandez  3   5 , Jordi de Batlle  5   6 , Jaume Benavent  7 , Juan Carlos Contel  8 , Erik Baltaxe  3   5 , Joan Escarrabill  3 , Juan Manuel Fernández  9 , Judith Garcia-Aymerich  4 , Miquel Àngel Mas  10 , Felip Miralles  9 , Montserrat Moharra  11 , Jordi Piera  10 , Tomas Salas  11 , Sebastià Santaeugènia  10 , Nestor Soler  3   5 , Gerard Torres  5   6 , Eloisa Vargiu  9 , Emili Vela  12 , Josep Roca  13   14
Affiliations
Review

Protocol for regional implementation of community-based collaborative management of complex chronic patients

Isaac Cano et al. NPJ Prim Care Respir Med. .
No abstract available

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Conflict of interest statement

The authors declare that they have no competing financial interests.

Figures

Fig. 1
Fig. 1
Aims of the study. Five pivotal aims to achieve successful regional adoption of the community-based protocol for collaborative management of complex chronic patients across healthcare tiers
Fig. 2
Fig. 2
Timeline of the protocol for large-scale deployment of CCP management in Catalonia. AISBE stands for integrated care area of Barcelona-Esquerra and BSA is the abbreviation of Barcelona Serveis Assistencials. A total of four codesign cycles, of 6-month duration each, are planned in each site. At the end of the assessment of the implementation studies (M42), a consensus on key performance indicators for follow up of integrated care interventions’ adoption beyond the current study will be achieved
Fig. 3
Fig. 3
General service workflow. General description of the service workflow through six sequential steps
Fig. 4
Fig. 4
Integrated Care Management of patients under LTOT
Fig. 5
Fig. 5
Stratification of the Catalan population (2014) using the GMA. Previously published in Dueñas-Espín I et al., BMJ Open. 2016 Apr 15;6(4) as part of the online supplementary material (Supplementary Figure 2S). The third and fourth columns depict rates of mortality and hospital admissions, respectively. The fifth column indicates the cost per inhabitant per year expressed in € and the last column refers the percentage of total healthcare expenditure by risk strata. It is of note that the closer the patient is to the tip of the pyramid, the higher are mortality, risk of hospital admission, and healthcare expenses. Green color (bottom) indicates healthy status, whereas red (tip) corresponds to maximum risk of admissions and highest mortality risk
See this image and copyright information in PMC

References

    1. Murray CJL, Lopez AD. Measuring the global burden of disease. N. Engl. J. Med. 2013;369:448–457. doi: 10.1056/NEJMra1201534. - DOI - PubMed
    1. Council conclusions “Innovative approaches for chronic diseases in public health and healthcare systems”. Council of the European Union 3053rd Employment. Social Policy Health and Consumer Affairs Council Meeting, Brussels. http://www.consilium.europa.eu/uedocs/cms_data/docs/pressdata/en/lsa/118... (2010).
    1. Innovative Care for Chronic Conditions: Building Blocks for Action. Geneva: World Health Organization (WHO/MNC/CCH/02.01). http://www.who.int/chp/knowledge/publications/icccreport/en/ (2002).
    1. Hernández C, et al. Integrated care services: lessons learned from the deployment of the NEXES project. Int. J. Integr. Care. 2015;15:e006. - PMC - PubMed
    1. Goodwin, N., Dixon, A., Anderson, G. & Wodchis, W. Providing integrated care for older people with complex needs: lessons from seven international case studies. Kings Fund. https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file... (2014). - PMC - PubMed

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