The co-creation and implementation of ADMIT, a novel integrated home-care model in Catalonia.

Background: With a growing population of elderly people, complex chronic illnesses, limited social resources, and an increasingly strained healthcare system, the need for an integrated care model has grown in Catalonia. The ADMIT Home Care Model aims to increase the time spent at home and quality of life of frail older adults with complex needs.

 

Approach: The ADMIT model is an iterative innovation developed by combining methods from implementation science, behavioral science, and computational science. A key component of the process is a participatory and co-creation approach with stakeholders. We used three enablers to drive the development and implementation of the model.

- Design and development of the care model and associated technologies (i.e., a digital platform to facilitate communication between health and social care professionals and the person cared for). We first conducted a situational analysis and a literature review to identify barriers and facilitators of organizational change, which informed the implementation process.

 

Through user-centered agile software development processes, we created digital solutions to support care delivery.

- Change management and progressive implementation of the model across three territories in Catalonia, involving twelve primary care centers, seven social service centers, and several acute and intermediate care hospitals in both urban and rural settings. The process is supported by robust training, on-site implementation support, and iterative adaptation to local contexts.

- Evaluation of outcomes and impact of the ADMIT model using mixed methods from implementation science at different stages. We aim to evaluate increases in “days spent at home,” reductions in acute clinical events, changes in frailty dimensions, and the experiences of professionals, care recipients, and caregivers.

 

 

Results: Findings: from the situational analysis highlighted several key aspects relevant to the development and implementation of the model.

During model construction, social and healthcare professionals co-created a roadmap beginning with a multidimensional assessment across both sectors and identifying resources to be integrated into a dedicated digital platform. Patients and caregivers participated in defining their care objectives and training needs, as well as evaluating the usability and intuitiveness of the digital platform.

 

We observed strong engagement among professionals, care recipients, and caregivers during focus groups. Throughout implementation, we identified the need for cultural change, professional training, and technological integration. Moreover, the definition of shared objectives among stakeholders emerged as a key driver for achieving interdisciplinary coordination and person-centered care. To date, more than 500 participants have been recruited, with over 300 social and healthcare professionals actively implementing the new model. As the ADMIT model continues to evolve, four additional releases are planned for further validation with all stakeholders through the end of the implementation project.

 

Implications: Adhering to the pillars of implementation science and participatory co-creation methodologies is essential for developing and implementing integrated care models. Our early insights indicate that achieving organizational alignment remains a challenge, offering lessons transferable to other contexts and contributing to the growing evidence base for home-based integrated care.