文章基本信息

标题：Evaluating the Impact of an Integrated Care Program
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作者：Ana Gómez ; Ana González González ; Javier Martínez Peromingo 等
期刊名称：International Journal of Integrated Care
电子版ISSN：1568-4156
出版年度：2017
卷号：17
期号：5
DOI：10.5334/ijic.3740
出版社：Utrecht University, Maastricht University, Groningen University
摘要：An introduction : The Strategy of Care for People with Chronic Diseases (SCPCD) is one of the main strategies in the Madrid Region. This strategy proposes some key elements for its application in each territory in order to achieve a better integrated-care, elements that include interventions that have proven to be effective and efficient as well as the adaptation of the care model to the needs of the patients. The Westernarea of Madrid, in particular, the area of influence of “Rey Juan Carlos” Hospital, is a territory where continuity of care and the integration of services has become a priority. It is the Madrid areawith the highest percentage of patients with high level of risk. The institutionalized population in nursing homes constitutes 2.5% of the total population and it is estimated that 4% of the population has complex chronic diseases. It is considered as one of the most advanced area in the application of new care routes and tools and also with initiatives such as a social and health plan for the integration between the hospital and social services and nursing homes. Short description of practice change implemented : Between 2012 and the present time, and with the impulse of the SCPCD as reference, different projects including effective and efficient integrated interventions have been implemented in this region. These interventions have been described in a previous work and they are: new coordination structures, new rolls, new pathways for people with complex needs and in nursing homes, new ways of communications between professionals of different organizations, and new IT tools, with a shared electronic Health Record. Aim and theory of change : The aim of the project is to evaluate the impact of an integrated care model in a territory within Madrid region, Spain. We will use as reference for obtaining indicators the "Report on Results in Chronicity" of the Madrid Region and the "Proposal of indicators to evaluate the attention to chronicity in the framework of the Strategy for Addressing Chronicity in the National Health System"of the Catalan Agency for the evaluation of health technologies. Finally, we will use the Conceptual Framework of the "Triple Aim" as a reference scheme for the construction of our map of indicators
关键词：implementation ; integrated care ; chronic diseases ; impact assessment