Building a Person-Centred Integrated Care Model for People with Complex Disabilities: Lessons from Aspace Catalunya’s Experience

Introduction: Fundació Aspace Catalunya is a non-profit organisation within the Catalan public health and social care network (SISCAT), dedicated to supporting people with complex disabilities and high dependency needs. Historically, this population faced fragmented care pathways, with limited coordination between health, social and educational services. In response, Aspace Catalunya has developed a comprehensive person-centred integrated care model that aligns with the WHO Integrated People-Centred Health Services (IPCHS) framework and the Catalan strategy for social and health integration. The initiative aims to ensure continuity of care, improve quality of life and optimise resources through a single governance, professional culture and digital ecosystem.

 

Methods: The model was designed and implemented using a participatory and evidence-based approach, involving professionals, families, and people with lived experience. The process followed four main phases: (1) mapping of existing workflows and identification of fragmentation points; (2) co-design of integrated pathways across residential, day care, and ambulatory neurorehabilitation services; (3) deployment of a unified electronic social and health record to ensure continuity of information and multidisciplinary coordination; and (4) capacity building among staff to consolidate shared values, digital skills, and leadership in integrated practice. Quantitative and qualitative indicators were used to monitor outcomes related to coordination efficiency, user experience, and professional satisfaction.

 

Results: After 36 months of implementation, the integrated model has demonstrated measurable improvements. Response times between interdisciplinary teams have been reduced by 42%, duplication of documentation decreased by 36%, and the proportion of coordinated care plans increased from 48% to 91%. Families reported higher satisfaction regarding communication and perceived continuity of care, while professionals highlighted enhanced collaboration and shared understanding of goals. The single digital record has enabled real-time tracking of social, health, and educational data, supporting early detection of risks and better allocation of resources. Furthermore, the model has contributed to strengthening partnerships with hospitals, primary care teams, and social services, promoting community-based continuity.

 

Conclusion: s: Aspace Catalunya’s model shows that integrated, digitally enabled, person-centred care can significantly improve outcomes for people with complex disabilities. The lessons learned highlight the importance of shared governance, professional development, and data-driven decision-making as enablers for scaling integrated care within the wider social and health ecosystem