title: [Care of the chronic patient in a complex situation: the challenge of building an integrated care scenario].
abstract: The ageing of the population and the increase in people with chronic illnesses is a scenario that creates important challenges on how to organise and provide services for this population group. There is already experience and evidence that would help us to re-think about what are the key aspects that should be taken into account to design a simple health model directed towards this new paradigm.The clinical care approach in itself is important, but at the same time, limited. A multidimensional approach is required where different elements, such as real platforms for change, are incorporated; the contribution that can be made by information systems, the objectives that should be assigned cross-sectionally to different organisations and professionals, the clinical and relational skills that should be contemplated in training and skill development plans or how the provision should be financed. Also, only interacting with some of these elements could give rise to a significant change in the care of chronic patients, particularly those in a highly complex and vulnerable situation.
authors.affiliation: DAP Costa Ponent, Gerencia Territorial Metropolitana Sud ICS, Pla Innovació Atenció Primaria i Salut Comunitària, Departament de Salut, Generalitat de Catalunya, Barcelona, España. jccontel@ambitcp.catsalut.net
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Contel
authors.forename: Blanca
authors.initials: B
authors.lastname: Muntané
authors.forename: Lourdes
authors.initials: L
authors.lastname: Camp
mesh_terms: D000368:Aged; D002908:Chronic Disease / Q000628:therapy*; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged