10th Apr 2018




  • Healthcare support programmes for nursing homes

Target Group:

  • Elderly living in institutionalised homes

A healthcare support programme for nursing homes launched in 2009 in Barcelona has been developed by teams of care homes (EAR). It comprises medical professionals and those with healthcare expertise in serving older people in nursing homes, understanding that these are indeed their homes.

Its aim is to provide comprehensive care, focusing on the individual. It seeks to adapt health and social resources and improve pharmaceutical services.

EAR teams work with the nursing homes’ healthcare professionals, with primary healthcare professionals, and other healthcare resources, to ensure healthcare continuity to this population.



  • The Chronic Patient Programme – Badalona Serveis Assistencials

Target Group:

  • Complex chronic and frail patients

Badalona Serveis Assistencials (BSA) is an integrated private care organisation, entirely funded by public capital. It manages the Hospital Municipal de Badalona, the Homecare Integrated Service, the Socio Health Centre El Carme, seven Primary Care Centres and the Centre for Sexual and Reproductive Health, providing care to a population of 419,797 inhabitants. Social services provision started in 2000, with full integration of health and social services since 2003.

Its objective is to focus on identifying, preventing and treating in advance acute episodes to avoid further hospitalisations; design and implement individual integrated care plans based on the evaluation of particular need and the general geriatric evaluation; promote independent living for these patients while maintaining good quality of life; and coordinate the work of the interdisciplinary teams doing the interventions.



  • Support of complex case management – AISBE

Target Group:

  • Complex patients that require linking tertiary care with the community

Complex case management aims for large scale deployment (ca. 3,000 patients) by integrating successful clinical programmes linking tertiary care with the community (Type I diabetes mellitus, rare diseases, LTOT, non‐invasive home-based ventilation, cardiac failure, HIV‐AIDS, COPD, major ambulatory surgery, sleep disorders, home hospitalisation, support pre‐and post‐surgical high risk procedures, etc.).

A specific programme addressing the management of multi‐morbid patients is included. Patients fulfil one of the following three criteria of complexity:

  • Need for highly specialised services directly delivered into the community
  • Need for coordination of several professionals across healthcare tiers
  • Need for management of frailty due to functional impairment and / or risk of social exclusion.

The aim is to coordinate care management of complex cases. Adaptive case management will be a core component. Tele-Health services aiming at enhancing patients’ accessibility to health professionals, as well as supporting remote monitoring, will be part of the program. Moreover, an open interoperability platform supporting adaptive case management across healthcare tiers and different providers will be implemented to support the service.



  • Collaborative self-management services promoting healthy lifestyles: physical activity AISBE

Target Group:

  • People in need of physical activity promotion

This is a community‐based service to promote physical activity (PA) in the healthcare sector of Barcelona‐Esquerra (AISBE). It seeks to show that tailored self‐management programmes with remote professional support can induce behavioural changes sustained over time leading to healthier life styles. The programme covers the following items: i) Workflow design of the PA service engaging both patients and health professionals; ii) Definition and development of ICT requirements; iii) Development of an evaluation strategy based on PDSA iterative cycles including collection of structured indicators; and, iv) Deployment of the novel service in the healthcare sector including innovative reimbursement incentives.

The goals of this novel PA service are twofold: i) To generate sustained enhancement of PA with an impact on health‐related quality of life in chronic patients; and ii) to have a cost‐effective impact on multi‐morbidities in terms of preventing occurrence. The outcome will be a roadmap to assess novel collaborative self‐management PA services in an urban health sector of Barcelona (300,000 citizens).



  • Integrated care for subacute and frail older adults (PSPV)

Target Group:

  • Subacute and frail older adults

Parc Sanitari Pere Virgili (PSPV) is the largest monographic geriatric post- and sub-acute resource in Catalonia, Spain. It is the reference facility in Catalonia for acute admission avoidance of older adults with flared-up chronic diseases or minor events superimposed to complex conditions such as dementia, and at risk of unnecessary hospitalisations. PSPV promotes admission avoidance thorough integrated care pathways which allow direct admission from the Emergency Department of two major University Hospitals in Barcelona (Vall d’Hebrón and Clinic University hospitals), and from reference primary care areas.