Moderate strength/good concordance; incorporating a grouping tool in the EMR helps as a reminder for taking more proactive/integrated decisions based on social and health needs of people with chronic diseases.

No abstract

Introduction: In order to achieve a successful integrated model, organizations must work in the development of six key elements that have been extensively described in the literature: coordination between policy makers and managers at regional and local levels; single entry to social and health care services; case management; individual care plan; autonomy functional assessment instrument; and shared electronic health record. The establishment of these mechanisms and tools enables the integration of different services and the implementation of an unique model of action, due to the participation and coordination of all those involved in it.

La visión clínica del profesional sanitario clave en la estratificación mediante la asignación niveles de intervención en el abordaje de los pacientes crónicos

Estrategia de implantación de un modelo de atención integrada a pacientes crónicos complejos