Table 1
Characteristics of patients and caregivers from different primary care centres. Onc: Oncological diagnostic; Non-onc: Non-oncological diagnostic; CCP: Complex chronic patient, ACD: Advanced chronic disease; we considered old man/woman if aged ≥65.
| ONC CCP | NON-ONC CCP | CARER OR FAMILY MEMBER ONC CCP | CARER OR FAMILY MEMBER NON-ONC CCP | ONC ACD PATIENT | NON-ONC ACD PATIENT | CARER OR FAMILY MEMBER ONC ACD | CARER OR FAMILY MEMBER NON-ONC ACD | FAMILY MEMBER AFTER ACD PATIENT DEATH | |
|---|---|---|---|---|---|---|---|---|---|
| Centre 1 | Old man | Young woman | |||||||
| Centre 2 | Old woman | Young man | Young woman | ||||||
| Centre 3 | Young man | Old woman | |||||||
| Centre 4 | Young woman | Old man | |||||||
| Centre 5 | Young woman | Old man | Old woman | ||||||
| Centre 6 | Young man | Old woman | |||||||
| Centre 7 | Old woman | Young man | |||||||
| Centre 8 | Old man | Young woman | Old man | ||||||
| Centre 9 | Old Man | Young woman | |||||||
| Centre 10 | Young woman | Old man | |||||||
| Centre 11 | Old woman | Young man | Young women |
Table 2
Composition of focus groups with health and social care staff.
| GROUP | PROFESSION/DISCIPLINE/SPECIALITY | UNIT/SETTING |
|---|---|---|
| Group 1 Identification of high needs | Nurse Nurse case manager General Practitioner General Practitioner Social worker Physician Geriatrician Pneumologist Internist | Outpatient primary care Home-based primary care Outpatient primary care Home-based primary care Outpatient primary care Emergency department Outpatient hospital care Outpatient hospital care Hospital-at-home |
| Group 2 Care planning | Nurse General Practitioner General Practitioner Social worker Cardiologist Occupational therapist Internist Administrative staff General Practitioner Director | Outpatient primary care Outpatient primary care Outpatient primary care Outpatient primary care Outpatient hospital care Hospital ward Hospital ward Outpatient primary care Home-based primary care Primary care team |
| Group 3 Crises management | Nurse case manager General Practitioner General Practitioner General Practitioner Pneumologist Physician Internist Nurse Internist Social worker Nurse | Home-based primary care Home-based primary care Acute home care Acute home care Day hospital Emergency department Hospital ward Day hospital Hospital-at-home Outpatient primary care Outpatient primary care |
| Group 4 Transitional care | Nurse case manager General Practitioner Social worker Nurse Administrative staff Coordinator Nurse Nurse Social worker | Home-based primary care Home-based primary care Hospital ward Hospital liaison Home-based primary care Hospital-at-home Outpatient hospital care Outpatient primary care Outpatient primary care |
| Group 5 End-of-life care | Nurse case manager General Practitioner Social worker Palliative care nurse Geriatrician Geriatrics nurse Palliative care physician Physician Director Physician | Home-based primary care Outpatient primary care Outpatient primary care Home-based palliative care Hospital-at-home Hospital ward Outpatient hospital Acute home care Primary care team Home-based primary care |
Figure 1
Evidence-based clinical practices for people with complex chronic conditions, in which health and social professionals agreed.
Table 3
Main characteristics of our programme.
| DIMENSION | PROGRAMA PROPCC METRONORD INSTITUT CATALÀ DE LA SALUT |
|---|---|
| Quality of information and communication | Ensuring patients and caregivers understand the information provided |
| Coordination and participation | Ensuring coordination between caregivers and professionals in managing health and social needs Ensuring social services when needed Providing support to caregivers in managing situations |
| Continuous healthcare and social support/accompaniment | Ensuring patients and caregivers feel supported throughout the process Enabling patients to be attended at home (if adequate care is available) Adopting a patient-centred approach |
Figure 2
Designing person-centred integrated care considering patients’, caregivers’, and professionals’ experiences.
Table 4
Summary of the key actions of the programme.
| 1. Identification of high needs |
| Weekly multidisciplinary meetings in primary care centres and hospital to detect high need-patients |
| 2. Definition and provision of an individualized care plan |
| Multidimensional assessment using Comprehensive Geriatric Assessment tools |
| Weekly multidisciplinary meetings in primary care centres: |
| Defining shared goals with patients |
| Defining therapeutic intensity level |
| Protocoled proactive visits |
| Health education on illness and care |
| Social needs assessment and service activation |
| Individualized care plan registers in electronic health record based on person values and priorities |
| 3. Management of health crises |
| Centralized response to acute crises |
| Acute response goal <12 hours |
| Direct access to alternative to hospitalization resources |
| Case management with direct communication between units |
| 4. Transitional care |
| Multidimensional assessment using Comprehensive Geriatric Assessment tools during hospitalization |
| Case management with direct communication between units during hospitalization |
| Care planning during hospitalization focused on return to home |
| Healthcare and treatment education |
| 5. End-of-life care |
| Exploring what matters most and social resources for end-of-life care at home |
| Early detection of palliative care needs |
| Advanced care planning with patients and caregivers |
| Meetings every 2 weeks for collaboration between units in and-of-life care at home/nursing home |