The Ministry of Health will bring order to the healthcare system with tailored plans for 300,000 chronically ill patients.

Barcelona"The tsunami of seniors is already here," warn sources from the Department of Health. Therefore, the authorities face a major challenge: adapting the healthcare system to the new social reality of an increasingly aging and fragile population. In fact, one in five Catalans over the age of 65 is not in good health and requires more intensive healthcare and social care than the rest. Currently, practically half of the regional budget—approximately €12 billion—is allocated to the care and treatment of these individuals, but the Department of Health admits that almost a third of these resources provide no benefit to patients. For example, duplications and contraindications arise between the different healthcare centers and specialists who treat them.

According to ARA, this year the department will begin to make "tailored" plans for all people with complex chronic conditions and in end-of-life situations, which number approximately 300,000. The objective: to reduce both the number of hospitalizations they must undergo throughout the year and the volume of medications they take and the visits they must have with the doctor. Thus, people with chronic illnesses will have a professional or a reference medical team that will act as a "one-stop shop" and will organize a care and pharmacological plan linked to their medical history, and which can be consulted from all health centers in the country, explains the director of Integrated Care and Chronic Conditions of the Department of Health, Jordi Amblàs.

This is one of the main measures included in the new 2025 Action Plan for the Integration of Care for Frail, Complex Chronic (PCC) or Advanced Chronic (MACA) People, to which this newspaper has had access. The program was created with the aim of offering more personalized care to the patients most dependent on the system. Currently, these patients have multiple healthcare plans, some of which may contradict each other, which can lead to decompensation, unnecessary travel, and hospitalizations, the expert admits. "Some of these patients can take up to 30 pills in a day. What we're looking for with this plan is to harmonize all the care they receive so that it's more appropriate and efficient," Amblàs maintains.

Fewer hospitalizations

Specifically, the initiative is aimed at older people with various chronic illnesses, such as diabetes, hypertension, or osteoarthritis; children and adolescents, although Amblàs has emphasized that, "fortunately, these are low-prevalence cases."

The department has identified around 300,000 people who need this more personalized care, 5% of the population, although government sources admit that there are more Catalans with this profile. An algorithm that, based on the data available in medical records, will suggest to healthcare professionals which patients could benefit from this more personalized care and, thus, gradually increase the number of people with a specific plan according to their level of fragility. money, but rather to adapt the care of the most vulnerable people. We prioritize ensuring that people can spend as much time as possible at home and not in a healthcare facility," the expert argues. Last year, they began offering these individualized plans to some patients and, according to data from Salut, they managed to reduce hospitalizations by 4% and readmissions by 6% per month, compared to patients with complex chronic conditions who did not have a personalized plan.

In addition to including these plans in patients' medical records, the Health Department will establish a network between different healthcare providers—primary care, intermediate care, acute hospital care, emergency medical services, nursing homes, and social services, among others—to improve patient transitions and avoid duplication. The department has dubbed them Territorial Complexity Routes, and they should serve to improve coordination within the healthcare system. Furthermore, professionals will be trained to understand the new plan and the new tools that will be implemented this year.

In addition to providing personalized treatment, the new plan also focuses on prevention. In this case, a pilot test will be carried out in 20 primary care centers (PCCs)—which have not yet been defined—to detect and reverse the frailty of older adults early. Specifically, these centers will offer specific programs for these patients with the goal of preserving their health and delaying the onset of chronic illness.

Amblàs explained that the intervention aims to ensure these patients exercise, maintain a healthy diet, have their health monitored to see if medication needs to be reduced or increased, and maintain an active social life to prevent unwanted loneliness. Furthermore, the Health Department's goal is to work hand in hand with the community and ensure these activities can be held in community centers or other municipal facilities.