Un modelo de atención integral al paciente crónico complejo: experiencia de un territorio.

INTRODUCTION: The Increase in life expectancy has brought an increase in chronic diseases. The evolution of chronic disease is the cause of several organic and systemic dysfunctions, leading to physical and mental limitations that determine the need for some aid to perform basic vital tasks. Primary health care has a key role in the monitoring of fragility, chronicity, and complexity of population. However, in order to address properly high complexity diseases it is necessary to know and coordinate the different resources existing inside the territory. THE DEVELOPMENT OF THE MODEL FOR ACTION: THE IMPLEMENTATIONS OF A FUNCTIONAL UNIT. The Primary Health Care must ensure equity, accessibility, longitudinally, and continuity of care, bearing in mind that health outcomes must be optimal. There are several health care providers in the Delta del Llobregat SAP, so it was implemented a strategic plan focused on the coordination and/or the reconciliation of all the devices involved in the assistance in order to provide comprehensive attention to the patient. The patients included in this program were to be identified as CCP (Complex chronic Patient), in an evolved and tributary phase of intensive follow-up. CONCLUSIONS. The identification ofpatients listed as CCP and at clinical risk allows a comprehensive monitoring in order to prevent exacerbations and overuse of unscheduled hospital resources.