Implementation of Clinical Communities of Practice for integrated care of complex patients aged 80+ in five Catalan territories

Background: Within the framework of the Transformational Project for Care Integration, funded by the Catalan Health System, implemented across five regions (Osona, Alt Maresme, Selva Marítima, Alt Empordà, and Baix Empordà), we present the outcomes of implementing Clinical Practice Communities (CPCs) as a collaborative tool among healthcare professionals. The project’s main goal is to establish an integrated care model for complex patients aged 80 and above.

 

The rise in multimorbidity and clinical complexity among older adults leads to reduced quality of life and increased healthcare utilization and costs. To address this, the Catalan Health Service has promoted the Complexity Care Pathway as a framework to enhance coordination across care levels. This pathway has been adapted to the organizational realities of each territory.

Due to the challenges in evaluating its implementation, CPCs have emerged as a key mechanism for shared monitoring among stakeholders, supporting a harmonized and context-sensitive rollout. The overarching aim is to advance toward integrated, person-centered care tailored to each region.

 

Approach: The project is structured around the design, implementation, and evaluation of an effective integrated care model, with two main components:

• Creation of CPCs: Collaborative workspaces for shared learning among professionals from different sectors and organizations, aimed at identifying common challenges and co-designing adapted solutions.
• Development of a technological platform: a support tool that facilitates resource selection, patient follow-up along the defined pathway, and identification of the reference professional.

Results:

Key actions included:

• Definition and structure: setting objectives, activities, and links with existing territorial structures. Each CPC includes representation from all entities and care lines, and a Promoting Group (5–7 members) with defined roles, coordination functions, and self-assessment criteria to ensure operational continuity.
• Institutional engagement: Agreements between entities with clearly defined responsibilities.
• Communication and awareness: Sessions with professionals and managers to ensure shared understanding.
• Territorial adaptation: CPCs are configured according to the characteristics, resources, and organization of each region, avoiding imposed professional profiles. Despite local adaptations, primary care, emergency, and intermediate care professionals are always consistently involved.
• Initial training: sessions to equip Promoting Groups with collaborative tools and management and evaluation strategies, supported by accessible and updatable documentation.
• Formalization: Four CPCs have been established, each with 15 to 23 members depending on the region’s size. CPC activities include territorial information review, clinical case analysis (successes and challenges), identification of training needs as drivers of change, critical review of scientific evidence and trends, and peer support to foster competency development.

 

Conclusion: CPCs have become a key instrument for the territorial implementation of the Complexity Care Pathway. They have fostered interprofessional collaboration, enabled the validation and adjustment of theoretical care circuits to real-world practice through case reviews, and supported data-driven territorial monitoring.