La atención al paciente crónico en situación de complejidad: el reto de construir un escenario de atención integrada / Care of the chronic patient in a complex situation: the challenge of building an integrated care scenario

El envejecimiento de la población y el aumento de personas con enfermedades crónicas constituye un escenario que plantea importantes retos en la manera como organizar y prestar los servicios para este grupo de población. Existen ya experiencias y evidencia que nos ayudan a repensar qué aspectos claves deberían ser tenidos en cuenta para diseñar un modelo sanitario sensible y orientado a este nuevo paradigma. El enfoque clínico asistencial por sí mismo es importante pero a su vez limitado; se requiere de un abordaje multidimensional donde se incorporen elementos diferentes como verdaderas palancas de cambio: qué aportación pueden realizar los sistemas de información, qué objetivos deben asignarse de manera transversal a diferentes organizaciones y profesionales, qué competencias clínicas y relacionales deberían contemplarse en los planes de formación y desarrollo de competencias o cómo se debe financiar la provisión. Además, sólo interactuando con varios de estos elementos se podrá llevar a cabo un cambio significativo en la atención a los pacientes crónicos, especialmente a aquellos que están en situación de mayor complejidad y vulnerabilidad(AU)

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(AU)

[Care of the chronic patient in a complex situation: the challenge of building an integrated care scenario]. / La atención al paciente crónico en situación de complejidad: el reto de construir un escenario de atención integrada.

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.