RESUMO
BACKGROUND: People with complex chronic conditions have multidimensional needs and often experience fragmentation in care. A model of integration was developed based on a case study of chronic wound management in Novo mesto, Slovenia. METHODS: JA CHRODIS Recommendations and Criteria were used as a framework for developing the practice. A baseline analysis, patient needs assessments and analysis of clinical pathways were performed using qualitative methodology. RESULTS: Baseline analysis identified facilitators and barriers to care. Patient needs assessment led to organizational solutions in health and social care. Analysis of clinical pathways proved high variability in treatment process. Using these results a model of integration was developed introducing protocol of care and care coordinator at the secondary (hospital) level. CONCLUSIONS: The proposed model would significantly reduce fragmentation in care for people with complex chronic conditions. The model was discussed at the policy dialogue and action plan defined for potential sustainability and scalability of the practice.
