title: [Complex chronic care situations and socio-health coordination].
abstract: Patient-centered healthcare is currently one of the most pursued goals in health services. It is necessary to ensure a sufficient level of cooperative and coordinated work between different providers and settings, including family and social and community resources. Clinical integration occurs when the care provided by health professionals and providers is integrated into a single coherent process through different professions using shared guidelines and protocols. Such coordination can be developed at three levels: macro, which involves the integration of one or more of the three basic elements that support health care (the health plan, primary care and specialty care), with the aim of reducing fragmentation of care; meso, where health and social services are coordinated to provide comprehensive care to elderly and chronic patients; and micro, aimed to improve coordination in individual patients and caregivers. The implementation of new roles, such as Advanced Practice Nursing, along with improvements in family physicians' problem-solving capacity in certain processes, or modifying the place of provision of certain services are key to ensure services adapted to the requirements of chronic patients.
authors.affiliation: Unidad de Residencias, Distrito Sanitario de Atención Primaria de Málaga-Valle del Guadalhorce, Espana; Grupo de investigación CTS 970 «Cronicidad, Dependencia, Cuidados y Servicios de Salud», España. Electronic address: jmorilla29@gmail.com.
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Morilla Herrera
authors.affiliation: Grupo de investigación CTS 970 «Cronicidad, Dependencia, Cuidados y Servicios de Salud», España; Facultad de Ciencias de la Salud, Universidad de Málaga, España.
authors.forename: José Miguel
authors.initials: JM
authors.lastname: Morales Asencio
authors.affiliation: Grupo de investigación CTS 970 «Cronicidad, Dependencia, Cuidados y Servicios de Salud», España; Unidad de Investigación del Distrito Sanitario de Atención Primaria de Málaga-Valle del Guadalhorce, España.
authors.forename: Shakira
authors.initials: S
authors.lastname: Kaknani
authors.affiliation: Grupo de investigación CTS 970 «Cronicidad, Dependencia, Cuidados y Servicios de Salud», España; Unidad de Investigación del Distrito Sanitario de Atención Primaria de Málaga-Valle del Guadalhorce, España.
authors.forename: Silvia
authors.initials: S
authors.lastname: García Mayor
mesh_terms: D003695:Delivery of Health Care; D006282:Health Personnel; D006301:Health Services Needs and Demand; D006801:Humans; D011320:Primary Health Care; D012947:Social Work
keywords: Anciano frágil; Comprehensive Health Care; Continuidad asistencial; Continuity of patient care; Cuidados de largo larga duración; Cuidados integrales; Frail elderly; Long-term care