Abstract
This study aims to inform the design of a service inbeded in SNS-National Health Service inclusing a digital personalized care plan in Portugal, a key figure in the care process for complex chronic patients, considering the lack of a uniform national response and the need for integrated and personalized care for these patients, addressing their specific challenges.
To achieve this, a co-creation methodology involving healthcare professionals and patients was used, with the objective of designing of a personalized care plan.
We did two workshops to evaluate four areas – Empathy, Needs, Responses, and Adaptations. The aim was to analyze the relevant areas for developing proposals for the personalized care plan, taking into account professionals and patients perspectives. One workshop was with healthcare professionals and included doctors, nurses, social workers, and psychologists, both from primary and hospital care, with a total of 22 participants from 5 institutions. The other involved representatives from chronic disease patient associations, counting with 25 participants. The co-creation approach ensured that both professionals and patients could express their expectations and perspectives, influencing the development of a personalized care plan to be implemented at a national level, , thus ensuring that the model aligns with the expectations and needs.
Preliminary results underscore the value of formalizing a national approach through the implementation of a dedicated case manager role, enhancing both care coordination and continuity for complex chronic patients. The analysis highlights several critical components: regular and structured communication between case managers and patients, which is essential for reducing anxiety and building trust; clearly defined care pathways with specific roles and responsibilities to ensure accountability and seamless transitions between care settings; and interoperable technological systems that enable efficient information sharing among healthcare providers. Additionally, the study emphasizes the importance of recognizing the social and familial context of patients to tailor support more effectively and enhance adherence to care plans. Healthcare professionals expressed strong expectations for this model to improve patient engagement, reduce administrative burden, and promote a balanced integration of clinical and administrative functions, promote higher satisfaction, increased trust, and a sense of security in navigating healthcare journey, benefiting from a personalized and responsive approach to managing their chronic conditions.
The findings of this study suggest that the personalized care plan, collaboratively developed as a cornerstone in the follow-up of complex chronic patients, represents a significant innovation in the design of care services focused on complex chronic patients, promoting more effective care integration and patient-centeredness. Furthermore, the plan fosters equity by providing a standardized, yet individualized, care approach accessible to all Portuguese citizens nationwide. It will be available to patients and any healthcare professional, regardless of location, ensuring consistent and continuous care across the country. With approximately 6% complex chronic patients in Portugal, the widespread implementation of this plan has the potential to significantly enhance the quality of care for this population, addressing their needs in a more cohesive and equitable manner.