Designing a Person-Centred Integrated Care Programme for People with Complex Chronic Conditions: A Case Study from Catalonia METHODOLOGY PAPER MIQUEL À. MAS MAGDALENA LLADÓ RAMÓN MIRALLES EDUARD MORENO-GABRIEL CONSOL HERAS AGUSTÍN URRUTIA MARIA J. ULLDEMOLINS MARIA A. ROCABAYERA JOSEP M. BONET NEMESIO MORENO-MILLAN NÚRIA PRAT JOSEP M. MODOL CORRESPONDING AUTHOR: Miquel À. Mas, MD, PhD MAR ISNARD ISABEL ANDRÉS Direcció Clínica Territorial de SARA PABLO ORIOL ESTRADA Cronicitat Metropolitana Nord, Institut Català de la Salut, SARA RODOREDA JORDI ARA DEL REY Catalonia, Spain; Department of Geriatrics Hospital JOAQUIM VERDAGUER PROPCC-BADALONA GROUP Universitari Germans Trias i *Author affiliations can be found in the back matter of this article Pujol, Badalona, Spain miquelmas.mn.ics@gencat.cat ABSTRACT KEYWORDS: integrated care; Introduction: The prevalence of people with complex chronic conditions is increasing. personcentredness;complex This population’s high social and health needs require person-centred integrated chronic conditions;programme approaches to care. design; multimorbidity, advanced conditions, older Methods: To collect data about experiences with the health system and identify people priorities for care, we conducted 2 focus groups and 15 semi-structured interviews involving patients with multimorbidity and advanced conditions, caregivers, and TO CITE THIS ARTICLE: representatives of patients’ associations. To design the programme, we combined this Mas MA, Miralles R, Heras C, information with evidence-based recommendations from local healthcare and social Ulldemolins MJ, Bonet JM, care professionals. Prat N, Isnard M, Pablo S, Rodoreda S, Verdaguer J, Lladó Results: Patients’ and caregivers’ main priorities were to ensure (a) comprehension of M, Moreno-Gabriel E, Urrutia A, information provided by healthcare professionals; (b) coordination between patients, Rocabayera MA, Moreno-Millan caregivers, and professionals; (c) access to social services; (d) support to caregivers N, Modol JM, Andrés I, Estrada in managing situations; (e) perceived support throughout the healthcare process; (f) O, Ara Del Rey, J. Designing home care, when available; and (d) a patient-centred approach. These dimensions a Person-Centred Integrated Care Programme for People were included in 37 of 63 clinical actions of the programme to cover the whole care with Complex Chronic trajectory: identifying high needs, defining, and providing care plans, managing crises, Conditions: A Case Study and providing transitional care and end-of-life care. from Catalonia. International Journal of Integrated Care, Conclusion: We developed an evidence-based integrated care programme tailored 2021; 21(4): 22, 1–12. DOI: to high-need patients combining input from patients, caregivers, and healthcare and https://doi.org/10.5334/ social care professionals. ijic.5653 Mas et al. International Journal of Integrated Care DOI: 10.5334/ijic.5653 2 INTRODUCTION AIMS AND OBJECTIVES OF THE ENGAGEMENT PROCESS Societal ageing and decreased mortality associated Following the strategy of the Government of Catalonia, with various conditions due to improved health-system Institut Català de la Salut, as main health public provider efficiency have led to an increase in the number of frail in our region, have developed a proactive strategy to older people and people with multimorbidity [1]. Various identify needs of people with complex chronic conditions. studies show there is a small group of people with complex To consolidate a standardised care model for these chronic conditions (such as multimorbidity, advanced populations, there were found as key actions not only to frailty or advanced illness) who are characterized by high target people with high health and social needs, but also health and social needs. This population, often referred to involve all actors in shared care plans. Thus, in designing to as “high-need, high-cost patients” [2], requires a a person-centred integrated care programme, reference person-centred approach; otherwise, their needs can go for the care of people with complex chronic conditions in unmet when fragmented care fails to cover one or more our institution, we aimed to draw on people’s experience conditions [3, 4]. This multiple needs coverage require an with healthcare to identify key clinical actions in order integrated approach; thus, it is imperative to develop and that their priorities and views could be included in the improve integrated care models to ensure the health and programme, integrating them with evidence-based social needs are met [5–10]. clinical actions proposed by clinicians. The objective of In designing these models to move from disease- the engagement process was to improve the quality of centred approaches to person-centred integrated care, it care through future organizational changes oriented is crucial to take people experience into consideration [11– towards the achievement of the adapted model of care 15]. Various initiatives in recent years have recommended emerged from this process. exploring people priorities and asking them what matters most [16, 17]. Furthermore, researchers have identified system-related and professional-related issues that METHODS should be considered in planning healthcare services for these people [18] and have identified key aspects related We defined a strategy to include the participation to communication/information, care management, and of patients and caregivers in the elaboration of the care coordination that should be included [19]. Metropolitana Nord Community-based Integrated Care Programme to People with Complex Chronic Conditions BACKGROUND OF THIS RESEARCH (Programa ProPCC MetroNord Institut Català de la Salut) Our purpose was contextualised in the framework of the [23], tailored to people with complex chronic conditions Health Plan of Catalonia [20]. In this context, the Catalan and high social and care needs, that would identify Chronic Care Programme was led in 2011 with a focus on key clinical actions for healthcare and social care staff improving the care of patients with chronic conditions. to perform at different points throughout the entire Main actions included: (a) to stratify the entire Catalan trajectory of care. The initiative was developed in the population and to identify risk groups to work proactively framework of the quality improvement process led by with them; (b). to establish a model for complex chronic the Metropolitana Nord Chronic Care Management Team, and advanced chronic conditions identification that from the Gerència Territorial Metropolitana Nord, of the generates shared intervention plans; (c). to define and Institut Català de la Salut. Its main aim was planning implement a proactive care and case management and evaluating innovative integrated care strategies for model; (d). to introduce a palliative care approach to patients with frailty and multimorbidity attended by our people with advanced chronic conditions; (e). to design teams located in the north of the metropolitan area of and implement a collaborative health and social model Barcelona, Catalonia. The project involved more than one for people with chronic conditions and higher levels of hundred people from the town of Badalona (third-largest dependence; (f). to implement a new complex chronic city in Catalonia) January through November 2018. care model for assessment and contracting; (g). to This strategy comprised two components: (C1) a guarantee health and social integrated care for people qualitative study to explore patients’ and caregivers’ with both complex chronic conditions and social care experiences and views; and (C2) a task group with needs. Last decade, different local providers adapted professionals to validate evidence-based key actions and their strategies to identify high need people to tailor to adapt them to their local contexts. care plans to two targeting populations derived from this programme [21]: complex chronic patients (CCP) C1. CAPTURING PATIENTS’ AND CAREGIVERS’ and patients who had advanced chronic disease (ACD). EXPERIENCE Several clinical programmes have been implemented Following the precepts of a contributory project [24] across the territory to develop and assess intervention to integrate the patients’ and caregivers’ views in strategies, following this identification [22]. designing the programme, we performed a qualitative 3 study with the aim to analyse patients’ and caregivers’ All interviews and group discussions with patients and experience regarding the services provided by the local caregivers were recorded and later transcribed. system to meet their high needs due to complex chronic Two researchers (MM and MU) contacted frontline conditions. staff from 11 Primary Care Centres to identify candidates who had previously been identified and registered in Sampling and data collection procedures the electronic health record with the labels CCP or ACD, We recruited a convenience sample of people with and with interest in being involved with the elaboration complex chronic conditions (including patients in need of the new programme. Physicians, nurses, and social of end-of-life care), caregivers supporting or having workers from these centres, and linked to our group (they supported them (in some cases the patient had recently were participants of the task group with professionals), died), and representatives of patient associations contacted patients and caregivers from their surgeries (oncologic and progressive non-oncologic diseases). (by a phone call or in the context of a visit for any clinical We established an interview schedule for sequentially or social reason). All candidates were informed that combining data collection and initial analysis of both they were invited to participate in this project as part group and individual interviews. An interview guide was of a quality improvement plan. Therefore, candidates designed to ask participants about their experiences agreeing to participate signed an informed consent throughout the entire trajectory of care, with specific document authorizing the investigators to register and questions about (1) high needs impact, (2) care plans, use the information derived from their participation. (3) management of crises, (4) transitional care, and (5) Table 1 outlines the characteristics of the patients and end-of-life care. The interviews were adapted to the caregivers recruited from the different primary care different types of participants (patients, caregivers, and centres. professionals). To gather information about patients’ and caregivers’ Interviewers recorded their observations on a data experiences, as well as facilitating triangulating their collection form specifically designed for this purpose. views, we combined three techniques: ONC NON- CARER CARER OR ONC ACD NON- CARER CARER FAMILY CCP ONC OR FAMILY PATIENT ONC ACD OR OR MEMBER CCP FAMILY MEMBER PATIENT FAMILY FAMILY AFTER ACD MEMBER NON-ONC MEMBER MEMBER PATIENT ONC CCP CCP ONC NON-ONC DEATH ACD ACD Centre 1 Old Young man woman Centre 2 Old Young Young woman man woman Centre 3 Young Old man woman Centre 4 Young Old woman man Centre 5 Young Old Old woman woman man Centre 6 Young Old man woman Centre 7 Old Young woman man Centre 8 Old man Young Old man woman Centre 9 Old Young Man woman Centre 10 Young Old woman man Centre 11 Old Young Young woman man women Table 1 Characteristics of patients and caregivers from different primary care centres. Onc: Oncological diagnostic; Non-onc: Non- oncological diagnostic; CCP: Complex chronic patient, ACD: Advanced chronic disease; we considered old man/woman if aged ≥65. 4 (a) focus groups (one for complex chronic patients C2. INPUT FROM HEALTHCARE AND SOCIAL and another for their caregivers). CARE PROFESSIONALS (b) semi-structured interviews with 19 patients and To incorporate professionals’ perspective and knowledge in caregivers (including patients with advanced the programme design, we created a focus group for each illness, their caregivers -often interviewed of the five stages of the care trajectory (identification of alongside the patients-, and caregivers of high needs, care planning, crises management, transitional patients who had died recently). care, and end-of-life care). Each group comprised 9 to 11 (c) in-depth interviews with representatives healthcare and social care individuals from our institution of 3 associations supporting patients with different backgrounds and professional roles providing with progressive disease (amyotrophic care in different contexts (primary and community care, lateral sclerosis, dementia, and intermediate care and hospital care). Table 2 reports the cancer). composition of the different groups. GROUP PROFESSION/DISCIPLINE/SPECIALITY UNIT/SETTING Group 1 Identification of high needs Nurse Outpatient primary care Nurse case manager Home-based primary care General Practitioner Outpatient primary care General Practitioner Home-based primary care Social worker Outpatient primary care Physician Emergency department Geriatrician Outpatient hospital care Pneumologist Outpatient hospital care Internist Hospital-at-home Group 2 Care planning Nurse Outpatient primary care General Practitioner Outpatient primary care General Practitioner Outpatient primary care Social worker Outpatient primary care Cardiologist Outpatient hospital care Occupational therapist Hospital ward Internist Hospital ward Administrative staff Outpatient primary care General Practitioner Home-based primary care Director Primary care team Group 3 Crises management Nurse case manager Home-based primary care General Practitioner Home-based primary care General Practitioner Acute home care General Practitioner Acute home care Pneumologist Day hospital Physician Emergency department Internist Hospital ward Nurse Day hospital Internist Hospital-at-home Social worker Outpatient primary care Nurse Outpatient primary care Group 4 Transitional care Nurse case manager Home-based primary care General Practitioner Home-based primary care Social worker Hospital ward Nurse Hospital liaison Administrative staff Home-based primary care Coordinator Hospital-at-home Nurse Outpatient hospital care Nurse Outpatient primary care Social worker Outpatient primary care Group 5 End-of-life care Nurse case manager Home-based primary care General Practitioner Outpatient primary care Social worker Outpatient primary care Palliative care nurse Home-based palliative care Geriatrician Hospital-at-home Geriatrics nurse Hospital ward Palliative care physician Outpatient hospital Physician Acute home care Director Primary care team Physician Home-based primary care Table 2 Composition of focus groups with health and social care staff. 5 Each group met in two to four sessions. In each collection forms. Next, we conducted a thematic analysis session, two moderators from the research team started [34] of the transcripts, combining both an inductive an open discussion on staff members’ experiences and a deductive approach. First, initial codes (e.g. legal providing care in their care trajectory stage. With the issues, emotional wellbeing, social barriers, beliefs, etc.) aim of defining evidence-based actions for their stages were derived from the content of the data themselves of the care trajectory, participants listed clinical actions by one of the co-authors (CH). Then, these codes were that could fulfil the needs of patients and caregivers. grouped into themes reflecting the key aspects regarding The clinical leaders of this project (MM and RM) validated the model’s definition (what was being done right, the main evidence for these actions for each stage unmet needs, and each person’s priorities) after being [25–30]. They used high-quality research selected based discussed by the co-authors (CH, MM & MJU). Then, we on a US Institute of Medicine’s approach on successful combined the information gathered from all the sources models of comprehensive care for older adults with about each aspect for each stage of the care trajectory, chronic conditions [31, 32]. Fifteen urging models were underlining key aspects and ideas, and placing special considered, including: interdisciplinary primary care emphasis on priorities to facilitate their incorporation [33], models that supplement primary care, transitional into the programme (Table 3 and Annex 1). care, models of acute care in patients’ homes, nurse- Throughout the analytical process, we took care physician teams for residents of nursing homes, and to ensure that discrepant views and priorities were models of comprehensive care in hospitals. According reflected in the analysis (e.g., some patients prefer to to these reviews, a graphic panel with evidence-based be attended by a specialist, even if this means waiting, good clinical practices throughout the care trajectory, in whereas others prefer to be attended immediately, even which health care and social professionals agreed was if this means being attended by a different professional). developed (Figure 1). Following Braun & Clarke’s reflexive approach to thematic analysis [35], we contend the adequacy of the notion of ANALYSIS saturation in this study, since we agree that meaning is Patient and caregivers’ experience generated and not excavated from data, therefore being The transcripts of the recordings from the interviews inescapably situated and subjective. For the purpose of and discussions were annotated with the observations this case study, we decided to conduct all interviews recorded by each interviewer/moderator in the data and focus group planned in order to mitigate missing Figure 1 Evidence-based clinical practices for people with complex chronic conditions, in which health and social professionals agreed. 6 DIMENSION PROGRAMA PROPCC METRONORD INSTITUT CATALÀ DE LA SALUT Quality of information and communication Ensuring patients and caregivers understand the information provided Coordination and participation Ensuring coordination between caregivers and professionals in managing health and social needs Ensuring social services when needed Providing support to caregivers in managing situations Continuous healthcare and social support/accompaniment Ensuring patients and caregivers feel supported throughout the process Enabling patients to be attended at home (if adequate care is available) Adopting a patient-centred approach Table 3 Main characteristics of our programme. Figure 2 Designing person-centred integrated care considering patients’, caregivers’, and professionals’ experiences. key themes, even though no new ones were identified were merged with actions derived from patients’ and especially towards the final interviews. caregivers’ experiences (Figure 2). At the end of the process, the results were member- Below, we list the guiding principles of the checked since all participants (patients, caregivers, and programme, illustrating them with an excerpt from an representatives of patients) received a letter from the interview or focus group with caregivers and participants researchers with adapted information related to the in order to highlight their critical role in defining main conclusions of the process, highlighting their input it. in the programme at the end of the process. A. To ensure that patients and caregivers Integrating healthcare and social care understand the information provided professionals’ experience As this participant states regarding the caregiver, this To decide which clinical actions should be included in priority corresponds to the demands of clear information the programme, two experts (RM & MM) reviewed the and smooth communication between all those involved contributions of different professionals (physicians, in the programme: nurses, social workers, administrative staff, occupational therapists, etc.) based on their experience and their “With just one explanation, the caregiver must knowledge in the care of vulnerable populations in become an expert on the topic” (GF_PCC). the local area, comparing them to evidence-based actions. B. To coordinate the management of health and The programme was designed by combining the social needs between patients, caregivers, and information derived from the experiences of patients, professionals caregivers, and professionals, taking care to ensure that Linked to the necessity of fluid communication, the contributions of the different groups of participants this priority adds a more practical dimension of could be traced and identifying where they were coordinating views, actions and decision making incorporated. (e.g. remaining at home and avoiding nursing home admission), namely allow participation in care planning: RESULTS “I fear he gets really sick and suffers. If this happens, I’d phone the nurse first thing. I trust him The ultimate result is an integrated care programme that and he shares my views: avoid nursing homes” includes 63 evidence-based actions, of which 37 (59%) (EP3 MACA). 7 C. To ensure that social services are available G. To facilitate a patient-centred approach when they are needed Somehow integrating the priorities listed above, this This priority highlights the relevance of covering physical priority highlights the importance of respecting patients’ and environmental needs, as this caregiver points out and caregivers’ values and preferences and allowing regarding the importance of a wheelchair, even over them to participate in care planning, even when these more health-related issues: contradict established clinical advice (as in the excerpt below): “I’ve never really needed anything. (…) Just once, I asked the government, the council, social care, etc. “The nephrologist told me to go to the hospital for for an electric wheelchair and it was rejected. I am everything. I was told this (an inhaler) could harm not talking about information but about something my heart but to avoid going to the hospital, I chose primordial. (…) that a 49-year-old can get out (…). this option. I told the nurse: “I found this, and I I am not asking for luxury but for people’s needs have done that” and she said: don’t do this more being taken into account. The doctor is amazing than three days but if you really need it, go ahead, but sometimes these other things are more it won’t hurt you and it can clean your lungs”, I did important” (GF CAREPCC). not want to get to the hospital at all” (GF PCC). D. To provide support to caregivers in managing situations DISCUSSION This priority is related to the need to not only involve but also provide specific support for family members and Our research has identified actions and priorities that caregivers, who often report feeling overwhelmed: are similar to those outlined in reference projects from the United Kingdom: National Voices [14] and Oxford “We need some help for the caregiver or a Picker Institute [16]. The main dimensions identified (different) caregiver some days a week… we are from the contributions of patients and caregivers in our exhausted at all levels” (EP3 PCC). study are those related to the quality of information and communication, coordination and participation, and E. To ensure that patients and caregivers feel continuous health and social support/accompaniment. supported throughout the entire trajectory of care In recent years, various groups have involved patients This priority relates to the emotional support, empathy, in service planning. In a scoping review of 22 studies and respect needed throughout all stages of the care reporting the experience of patients with multimorbidity, process, highlighting its dynamism (e.g. intense support van der Aa et al. [18] identified 12 categories of experience to Primary Care teams by hospice at home teams with the healthcare process, dividing problems into may be needed in some cases of complexity) and the those considered system-related (burden of care, lack requirement of continuity of care and soft transitions: of organization, poor communication and insufficient access to care) and those considered professional- “The palliative care nurse came home only until I related (competencies, managing information, attitude learned how to manage morphine regulation” (EP2 towards vulnerable patients and carers, guidance, MACA). communication skills, holistic view, familiarity, and patient involvement). Shiotz et al. [19] conducted semi- F. To enable patients to be attended at home structured qualitative interviews with 14 patients with (if care is available) multimorbidity, identifying three dimensions related This priority relates to a general (but not unanimous) with continuity (information continuity, management claim of receiving effective, care by familiar, trusted staff continuity, and relational continuity). These authors at home. As this participant points out, home care is seen identified a dichotomy in patients’ reports about their as a priority but acknowledging this may have some care experience: on the one hand, patients reported many limitations and should not prevail over the patient’s problems and areas in which care could be improved; on wellbeing (e.g. feeling calmed): the other hand, however, they also reported that they were mostly satisfied with and thankful for the care they “I know my father will get worse, but we all want received. These authors conclude that patients like to be him to stay at home until the end if he’s calmed. treated as a whole person by healthcare professionals He’s already been attended by the home care with time who collaborate with other professionals palliative care team once and it was great” (EP1 across the system to provide specialized care to manage CAREPCC). their complexity. They also underline the importance 8 of medication management. In a multicentre quality Our work integrated the viewpoints of patients, study involving 172 patients with multimorbidity and caregivers, and professionals to design a new model of caregivers, Kuluski et al. [17] sought to ascertain the integrated care in a territory. We provided the means priorities of patients and their caregivers regarding care. and opportunity for those living with complex chronic They found that the priorities were (a) feeling heard, conditions, and their family members and caregivers, appreciated, and comfortable; (b) having someone to to express their views about how healthcare services count on; (c) having easy access to health and social can best meet their needs. Likewise, we considered it care; (d) knowing how to manage health and what to important to incorporate the viewpoints of the different expect; (e) feeling safe; and (f) being independent. To professionals involved in caring for these patients into a understand healthcare professionals’ perspectives about new, person-centred approach to managing these high- managing patients with multimorbidity, Sinnott et al. [30] need patients. The model resulting from this quality synthesized the findings from 10 studies including a total process (Table 4) is in the same line as advocated by of 275 general practitioners in 7 countries. They found Poitras et al. [25] based on their scoping review, which that problematic aspects of managing these patients fell underlined the importance of promoting evidence-based into four areas: the disorganization and fragmentation decision making, adopting patient-centred approaches, of healthcare, the lack of guidelines adapted to patients enabling patient self-management, facilitating case/care needing complex care, the difficulties involved in management, promoting interdisciplinary approaches, delivering patient-centred care, and barriers to shared developing training for healthcare professionals, and decision-making. integrating information technology. 1. Identification of high needs Weekly multidisciplinary meetings in primary care centres and hospital to detect high need-patients 2. Definition and provision of an individualized care plan Multidimensional assessment using Comprehensive Geriatric Assessment tools Weekly multidisciplinary meetings in primary care centres: Defining shared goals with patients Defining therapeutic intensity level Protocoled proactive visits Health education on illness and care Social needs assessment and service activation Individualized care plan registers in electronic health record based on person values and priorities 3. Management of health crises Centralized response to acute crises Acute response goal <12 hours Direct access to alternative to hospitalization resources Case management with direct communication between units 4. Transitional care Multidimensional assessment using Comprehensive Geriatric Assessment tools during hospitalization Case management with direct communication between units during hospitalization Care planning during hospitalization focused on return to home Healthcare and treatment education 5. End-of-life care Exploring what matters most and social resources for end-of-life care at home Early detection of palliative care needs Advanced care planning with patients and caregivers Meetings every 2 weeks for collaboration between units in and-of-life care at home/nursing home Table 4 Summary of the key actions of the programme. 9 Several limitations and considerations related to the LESSONS LEARNED AND FUTURE VISION nature of the co-design process in people with complex • Querying people with complex chronic conditions and chronic conditions and their caregivers were identified. their caregivers identified the following dimensions Firstly, we found difficulties in the engagement process. that should be prioritized in the elaboration of a more Circumstances made it necessary to partially modify patient-centred approach to their care: the quality of the strategy that had been planned. Although the focus information and communication, coordination and groups provided ample useful information, attendance participation, and continuous support/accompaniment was lower than expected (only 6 patients and 5 family by social care and healthcare professionals. These caregivers) because some patients’ conditions had priorities were converted into clinical actions that worsened, so neither they nor their caretakers could affected more than 50% of the actions in the attend. To ensure that all patients and caregivers could evidence-based integrated clinical care programme participate, we interviewed them in their homes, thus elaborated in collaboration with healthcare and social increasing the number of visits and prolonging data care professionals from our institution. collection. Despite these drawbacks, this approach • Involving the public in improving the process and ensured a more representative selection of patients and organization of care requires the dedication of caregivers by including those who were especially frail additional resources, mainly professionals’ time and complex. Secondly, we assume that the voluntary and knowledge, but the contributions of patients participation of people (patients and caregivers) with and caregivers help ensure that we take their special motivation to collaborate in the care improvement experiences into account in designing and improving process implies a bias related with the nature of our care programmes, to meet their needs in accordance pragmatic approach. Thirdly, despite reporting to the with their preferences and priorities. participants the highlights of their input in the final • Sharing this rigorous practical collaborative project version of the programme at the end of the process, has helped clinical and organizational leaders and more feedback is needed to monitor the adaptation of professionals to rediscover the value of prioritizing the programme to their views and needs. The fact of not patients’ priorities. We are aware that this has not including patients and caregivers in the design of key been a pure co-production process, but a first step actions leads to an incomplete co-design process. This for our institution towards service co-designing of inclusion was considered too complex in our approach complex interventions’ care, tailored to high-need to the design of our study, due to cultural reasons and vulnerable individuals and populations. other organisational factors. We will take this situation • Our next step will be engaging patients and in consideration for future updates of our care model caregivers in the systematic evaluation of the strategy, based on the successful results of this initial programme, combining qualitative and quantitative experience. methods to measure and monitor patients’ needs Finally, we would like to highlight the impact of and wellbeing. this quality process in the development of the new model. Through 2019 and the first trimester of 2020, the task continued with several meetings with ADDITIONAL FILE directors and clinical leaders of the region to translate it into redesign service production, at a community The additional file for this article can be found as follows level, and at intermediate care and acute hospital level. Key actions of the programme were used as a • Annex 1. List of priorities to convert in actions for standard quality framework for the detection of high- the entire care trajectory. DOI: https://doi.org/10.5334/ need high patients and for the case management ijic.5653.s1 provision across the care continuum. Most units could modify their care without major structural changes in their teams, but Metropolitana Nord Primary Care ACKNOWLEDGEMENTS teams and the Department of Geriatrics of Hospital Universitari Germans Trias i Pujol, decided to build new We thank all the individuals that participated in the focus multidisciplinary case management units, with expert groups and in individual interviews. social and health staff, to improve to provision of person- We also thank to Montserrat Tàrraga, Júlia Creus, centred care based on the care recommendations of Jenifer Mingorance and Mercedes Romero for their the new programme. The validation of the model was technical support, and Eulàlia Masachs, Roser Bosser, interrupted due to the Covid-19 pandemic in 2020. Oriol Garcia and Marta Hurtado, members of the We are working on completing the evaluation of the Department of Health of the Government of Catalonia, project, by following the ProPCC-Badalona cohort for their help during patients and caregivers’ interviews, evolution [36]. and Marga Queralt, for providing administrative support. 10 REVIEWERS Magdalena Lladó orcid.org/0000-0002-6947-6934 Direcció d’Atenció Primària Metropolitana Nord, Institut Català de la Salut, Catalonia, Spain; Servei d’Atenció Primària Jordi Amblàs-Novellas, Central Catalonia Chronicity Barcelonès Nord i Maresme, Institut Català de la Salut, Research Group, Chair of Palliative Care, Faculty of Badalona, Catalonia, Spain Medicine, University of Vic-Central University of Catalonia, Eduard Moreno-Gabriel orcid.org/0000-0001-8184-6232 08500 Vic, Spain. Direcció d’Atenció Primària Metropolitana Nord, Institut Anneli Hujala, Senior researcher, Department of Català de la Salut, Catalonia, Spain; Research Support Unit Health and Social Management, University of Eastern Metropolitana Nord, Primary Care Research Institute Jordi Gol Finland, Finland. (IDIAPJGol), Mataró, Spain Agustín Urrutia orcid.org/0000-0002-7508-5091 Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Spain. Universitat COMPETING INTERESTS Autònoma de Barcelona, Catalonia, Spain Maria A. Rocabayera The authors have no competing interests to declare. Direcció d’Atenció Primària Metropolitana Nord, Institut Català de la Salut, Catalonia, Spain Nemesio Moreno-Millan orcid.org/0000-0002-1617-9549 AUTHOR AFFILIATIONS Direcció d’Atenció Primària Metropolitana Nord, Institut Català de la Salut, Catalonia, Spain Miquel À. Mas orcid.org/0000-0002-8756-3783 Direcció Clínica Territorial de Cronicitat Metropolitana Nord, Josep M. Modol Institut Català de la Salut, Catalonia, Spain; Department of Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Geriatrics, Hospital Universitari Germans Trias i Pujol, Badalona, Spain Catalonia, Spain Isabel Andrés orcid.org/0000-0003-1414-064X Ramón Miralles orcid.org/0000-0002-7770-7819 Hospital Universitari Germans Trias i Pujol, Badalona, Catalonia, Direcció Clínica Territorial de Cronicitat Metropolitana Nord, Spain Institut Català de la Salut, Catalonia, Spain; Department of Oriol Estrada orcid.org/0000-0003-1414-5000 Geriatrics, Hospital Universitari Germans Trias i Pujol, Badalona, Gerència Territorial Metropolitana Nord, Institut Català de la Catalonia, Spain. Universitat Autònoma de Barcelona, Salut, Catalonia, Spain Catalonia, Spain Jordi Ara Del Rey orcid.org/0000-0002-7281-9969 Consol Heras Gerència Territorial Metropolitana Nord, Institut Català de la Direcció d’Atenció Primària Metropolitana Nord, Institut Català Salut, Catalonia, Spain de la Salut, Catalonia, Spain ProPCC-Badalona Group* (members in alphabetical order): Maria J. Ulldemolins orcid.org/0000-0002-6623-6302 Salvador Altimir, Margarita Álvaro, Alba Barranco, Gloria Bonet, Direcció d’Atenció Primària Metropolitana Nord, Institut Montserrat Bonet, Montserrat Bret, Anna Champer, Beatriz Díaz, Català de la Salut, Catalonia, Spain; Servei d’Atenció Primària Mar Domingo, Ria Garcia, Sonia Gracia, Carme Grau, Jaume Barcelonès Nord i Maresme, Institut Català de la Salut, Guitart, Maria Heras, Eva Hernández, Ramona Hervás, Sonia Badalona, Catalonia, Spain Jiménez, Yolanda López, Natalia Maella, Helena Manjón, Alicia Josep M. Bonet orcid.org/0000-0002-7981-5880 Marín, Josefina Martínez, Montserrat Mas, Sonia Mimoso, Núria Direcció d’Atenció Primària Metropolitana Nord, Institut Català Miralles, Celia Morcillo, Núria Moreno, Xavier Muntada, Laura de la Salut, Catalonia, Spain Nadal, Mercedes Navarro, Carme Nogueras, Raquel Nuñez, Cristina Pacho, Lidia Pedrejón, Carmen Pereira, Josep M. Picaza, Núria Prat orcid.org/0000-0003-1689-9017 María Puertas, Carmen Rios, Laura Rodríguez, Mercè Serrano, Direcció d’Atenció Primària Metropolitana Nord, Institut Català Antonia Segura, Boris Trenado, Julia Trigueros, Tathiana Vértiz, de la Salut, Catalonia, Spain Daniel Vilar, Mario Vinardell Mar Isnard orcid.org/0000-0001-6297-8520 *All members affiliated to Institut Català de la Salut except Direcció d’Atenció Primària Metropolitana Nord, Institut Català Margarita Álvaro, affiliated to Institut Català d’Oncologia. de la Salut, Catalonia, Spain Sara Pablo orcid.org/0000-0002-2001-6670 Direcció d’Atenció Primària Metropolitana Nord, Institut Català REFERENCES de la Salut, Catalonia, Spain Sara Rodoreda orcid.org/0000-0002-9955-8578 1. Marengoni A, Angleman S, Melis R, Magiaslasche Direcció d’Atenció Primària Metropolitana Nord, Institut F, Karp A, Garmen A, Meinow B, Fratiglioni L. Català de la Salut, Catalonia, Spain; Servei d’Atenció Primària Aging with multimorbidity. 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DOI: http://doi. perspectives on the management of patients with org/10.5334/ijic.ICIC20395 TO CITE THIS ARTICLE: Mas MA, Miralles R, Heras C, Ulldemolins MJ, Bonet JM, Prat N, Isnard M, Pablo S, Rodoreda S, Verdaguer J, Lladó M, Moreno-Gabriel E, Urrutia A, Rocabayera MA, Moreno-Millan N, Modol JM, Andrés I, Estrada O, Ara Del Rey, J. Designing a Person-Centred Integrated Care Programme for People with Complex Chronic Conditions: A Case Study from Catalonia. International Journal of Integrated Care, 2021; 21(4): 22, 1–12. DOI: https://doi.org/10.5334/ijic.5653 Submitted: 25 November 2020 Accepted: 15 October 2021 Published: 25 November 2021 COPYRIGHT: © 2021 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/. International Journal of Integrated Care is a peer-reviewed open access journal published by Ubiquity Press.