The development of a successful integrated care model / El desarrollo de un exitoso modelo de atención integrada

Introduction:In order to achieve a successful integrated model, organizations must work in the development of six key elements that have been extensively described in the literature: coordination between policy makers and managers at regional and local levels; single entry to social and health care services; case management; individual care plan; autonomy functional assessment instrument; and shared electronic health record.The establishment of these mechanisms and tools enables the integration of different services and the implementation of an unique model of action, due to the participation and coordination of all those involved in it.Description of the policy, its objectives and targeted population: The Strategy for the Care of Patients with Chronic Diseases in the Madrid Region is developing an innovative model of integrated care aimed at people with multimorbidity and complex needs which objective is to facilitate access to health and social care.Despite the development of regulatory and structural elements that can be more complex to achieve, the functional development of health integration models that have shown positive results guide and is guiding our actions.Conclusión: Muchos de los elementos propuestos son trasladables a nuestros y otros modelos de atención.En la Comunidad de Madrid, estamos trabajando alineados Actualmente, las experiencias locales y los avances en este sentido ya existente.

Abstract licence: CC BY

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