Abstract
Background: Personalised Action Plans (PAPs) are a key element to provide integrated care for complex chronic patients in the Andalusian Health Service. PAPs are implemented in primary healthcare centres in collaboration with other levels of care and are based on a comprehensive assessment of key aspects of the patient status, including targeting symptoms, functionality and quality of life as well as their preferred desired outcomes. Plans are designed by multidisciplinary teams (family physicians, nurses, internists, case manager nurses, pharmacists, social workers among others), with the collaboration of each patient and/or caregiver. PAPs are regularly reviewed and revised depending on patient status and needs and are recorded and stored in the corporate electronic health record system. Addressing patients needs and expectations is a essential part of PAPs, facilitating patient empowerment and commitment to the agreed outcomes.
Approach: PAPs were selected as one of the best practices to be included in the Joint Action on the transfer of best praCtices In pRimary CarE (CIRCE-JA), launched in February 2023, with a duration of three-year. Its overall objective is to effectively transfer and implement six identified PHC best practices (BPs) into 42 new implementation sites across EU Member States (MS), with scientifically robust evidence-based approach, to ensure sound transferability methodology. Critically, it aims to increase MS capacity to deploy innovative care models in PHC and to effectively support health system transformation at this level of care.
CIRCE-JA is a collaborative effort with 14 MS participating, bringing together 48 entities. The PAPs best practice is being transfer to 12 implementation sites, located in Estonia, Greece, Italy, Poland, Portugal and Slovenia. This implementation is based on the alignment of key BP characteristics to meet the local healthcare needs and priorities and match them with national and regional policies.
Results: The transferring process and key characteristics to be implemented in the different implementation sites will be described. This process has included initial workshops and webinars to describe the elaboration of the PAPS, sharing of information and documentation available as well as published references of the best practice, and a study visit. All implementing sites had the opportunity to benefit from watching the elaboration of a PAP directly in a healthcare centre by healthcare professionals (mainly nurses and family physicians). Adaptations will be needed to customize the PAPs in the 12 sites, with different healthcare systems and organizations. Collaboration between BP originator and all implementers as well as sharing experiences among implementers have facilitated the transferring process.
Other key aspects of the integrated care for complex chronic patients in Andalusia are the elaboration of a new comprehensive plan for integrated care of this type of patients, as well as expanding the digital solutions to include tele-monitoring in the case of these patients.
Implications: Transferring best practices can be a real challenge when implementing a already stablished practice from one location to another with a different healthcare system and organization.