title: Chronic and integrated care in Catalonia.
abstract: BACKGROUND
  The Chronicity Prevention and Care Programme set up by the Health Plan for Catalonia 2011-2015 has been an outstanding and excellent opportunity to create a new integrated care model in Catalonia. People with chronic conditions require major changes and transformation within the current health and social system. The new and gradual context of ageing, increase in the number of chronic diseases and the current fragmented system requires this transformation to be implemented.
  
  
  METHODS
  The Chronicity Prevention and Care Programme aims to implement actions which drive the current system towards a new scenario where organisations and professionals must work collaboratively. New tools should facilitate this new context- or work-like integrated health information systems, an integrative financing and commissioning scheme and provide a new approach to virtual care by substituting traditional face-to-face care with transfer and shared responsibilities between patients, citizens and health care professionals.
  
  
  RESULTS
  It has been observed some impact reducing the rate of emergency admissions and readmission related to chronic conditions and better outcome related to better chronic disease control. Some initiative like the Catalan Expert Patient Program has obtained good results and an appropriate service utilization.
  
  
  CONCLUSIONS
  The implementation of a Chronic Care Program show good results but it is expected that the new integrated health and social care agenda could provoke a real change and transformation. Some of the results related to better health outcomes and a decrease in avoidable hospital admissions related to chronic conditions confirm we are on the right track to make our health and social system more sustainable for the decades to come.
authors.affiliation: Chronicity Prevention and Care Programme. Ministry of Health.
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Contel
authors.affiliation: Interministerial Social and Health Care and Interaction Plan (PIAISS). Ministry of the Presidency.
authors.forename: Albert
authors.initials: A
authors.lastname: Ledesma
authors.affiliation: Chronicity Prevention and Care Programme, Ministry of Health.
authors.forename: Carles
authors.initials: C
authors.lastname: Blay
authors.affiliation: Chronicity Prevention and Care Programme, Ministry of Health.
authors.forename: Assumpció González
authors.initials: AG
authors.lastname: Mestre
authors.affiliation: Catalan Public Health Agency of Catalonia.
authors.forename: Carmen
authors.initials: C
authors.lastname: Cabezas
authors.affiliation: CatSalut. Commissioning Health Authority in Catalonia.
authors.forename: Montse
authors.initials: M
authors.lastname: Puigdollers
authors.affiliation: CatSalut. Commissioning Health Authority in Catalonia.
authors.forename: Corine
authors.initials: C
authors.lastname: Zara
authors.affiliation: Chronicity Prevention and Care Programme, Ministry of Health.
authors.forename: Paloma
authors.initials: P
authors.lastname: Amil
authors.affiliation: Interministerial Social and Health Care and Interaction Plan (PIAISS), Ministry of the Presidency.
authors.forename: Ester
authors.initials: E
authors.lastname: Sarquella
authors.affiliation: Directorate-General for Health Research and Planning, Ministry of Health.
authors.forename: Carles
authors.initials: C
authors.lastname: Constante
keywords: chronic care; expert patient; integrated care; multimorbidity