Program for Prevention and Treatment of Chronicity with HF patients – Alt Penedès

Good practice:

The use of a specific contact person to coordinate care as part of a patient centred model of care

CATALONIA  / Programme for Prevention and Treatment of Chronicity with HF patients – Alt Penedès:  NA/1438 13/19

The Programme for Prevention and Care of Chronicity (PPAC) provides a new model of health and social care for the Catalan people. With the focus on long-term conditions like heart failure, COPD and diabetes mellitus. PPAC was launched by the Catalan Ministry of Health and the Ministry of Social Welfare and Family.

Customer's need

PPAC aims to develop comprehensive clinical processes for the chronic conditions. It will help construct integrated care pathways for hospital, primary care centres, nursing home facilities and social services. PPAC also aims to provide proactive care of patients with complex disease and advanced chronic disease. This will assure a 24/7 coverage model. With good response to potential exacerbations of this group of patients. The PPAC programme in Alt Penedès includes chronic care patients with heart failure and/or COPD and two comorbidities.

The solution

PPAC was launched to plan and carry out interventions to:

  • Reduce hospital readmissions.
  • Reduce urgent care needs.
  • Improve transactions in case of emergencies.
  • Maintain functional status and quality of life of the patients.
  • Improve patients’ perception of quality of life.
  • Improve professional management of these patients.

We have a chronic care team made up of physiciansn nurses, health and social care professionals. They organise professional care using a flexible, integrated, proactive care model.

A change in the provision of services was needed, using a model of shared care to improve communication. In addition, there were other aspects implemented. These include: 

  • Sharing information through the use of the shared clinical record.
  • Involving patients and families in selfcare.
  • Training professionals.
  • Assessing the development of the programme through indicators to detect which aspects to improve.

Keys to success

  • The case manager is the key reference point especially in the primary care setting.
  • Developing a day hospital unit at the Primary Care Clinical Record (HCAP) to attend to complex chronic patients. Especially those at risk of destabilisation, or mild to moderate exacerbations. This unit starts along with the Programme, and is defined as: Acute Chronic Patient Unit (UPCA).
  • Establishing a training plan for all involved professionals prior to the implementation of the programme and follow up.

Good practice: The use of a specific contact person to coordinate care as part of a patient centred model of care.

Good practice description

Patients are more supported when they are assigned a contact person who guides them through the programme. This markedly improves their overall experience of care. A contact person is one key person whose remit in relation to care will differ dependent on the healthcare system. For example, a professional with advanced knowledge of complex conditions. Or a more general person to oversee milder chronic conditions.

The use of a specific contact person gave enhanced control of chronic diseases and opportunity to provide more coherent, integral and individual care. There was also the possibility of earlier intervention and, therefore, more proactive treatment.

“The programme gives security to the professionals when making decisions. The patient feels more accompanied. Which improves his or her perception of quality of care and quality of life. For the organisation, it optimises resources and improves efficiency, efficacy and care”.

Good practice example

Significant change was reported where healthcare services adopted a patient centred healthcare model, and a shared decision making approach. Coupled with the decision to invest in a programme. This is the case of the PPAC in Alt Penedes, resulting in outstanding experience for patient adherence.

The program

Organise care by professionals based on an integrated, proactive and flexible service model. This will enable appropriate response to the needs of this population. Improving the efficiency of the system in the context of clinical practice guidelines and care pathways. 

Modify the provision of services with a shared care model among:

  • Primary care.
  • Case management.
  • Specialised care teams and/or other services:
    • Territory-based Continued and Emergency Care Units-ACUT
    • Home Healthcare and Support Team Programme-PADES
    • Long Term care

The programme included the following interventions:

  • Ensure the service 24h – territorybased Continued and Emergency Care Units.
  • Reach consensus on Primary Care Specialist-Healthcare health paths.
  • Involve the patient and their family in their self cure.

This last intervention helps promote maximum independence, and prevents the progression of complexity and dependency.

The programme is for patients above 69 years with the following inclusions criteria: diagnosed with HF and/or COPD and having three comorbidities (COPD, asthma, HF, isquemic cardiopathy, diabetes, AVC, dementia, hypertension, mental disorder or Parkinson.

Contact information

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Pilar Piñeiro

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José Carlos Molina


  • Economic evaluation of a program of coordination between levels for complex chronic patients’ management. Annals de Medicina. Volume 47, Issue 3, March 2015, Pages 134–140
  • Guia per a la implementació territorial de projectes de millora en l’ateddnció a la complexitat

Program partners