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Introduction Along with the Covid-19 pandemic, the social and health systems faced a great challenge, particularly in institutionalized patients. An integrated care emergency response was required, not only for the Covid-19 impact on health outcomes but for the complexity of the pandemic control in long term care facilities (LTCF). Due to a lack of evidence on how to respond to new pandemic disease, we created a multidisciplinary group from a network of public primary care teams (PCT), to set up and unify the implementation of the strategic lines in management of the Covid-19 emergency in LTCF. All decisions were taken under expert's consensus and they were implemented by a learning-by-doing method, based on protocols, IT solutions expressly implementation, and strategies shared with local health and social authorities. Aim The aim was to set up and unify the implementation of the strategic lines in Covid-19 prevention, diagnostic and clinical management along with all LTCF of our area. We were urged to develop different clinical protocols to deliver patient-centred care tailored to the needs derived from the different stages of the emergency. Targeted population 10,688 residents from 196 LTCF (169 nursing homes and 27 institutions for people with physical and mental disabilities). A network of public and private stakeholders collaborated to implement multilevel strategies supported by the Government of Catalonia. Timeline Started in March 2020. We defined three phases. First wave: March to June (developing and setting up strategic lines); Off-peak (between waves): June to October (strengthening disease control prevention); Second wave: October until December 2020 (applying all lessons learned along the process). Highlights 64 PCT led the response to guarantee 24 hours seven days a week care. Massive testing to residents and workers was introduced. New IT implemented solutions were: coVIDApp (to improve daily communication with LTCF staff, by sharing information on disease control and patient's needs) and Covid-19 LTCF intranet business object platform (for clinical and epidemiological indicators follow-up). We developed a necessary basic conditions checklist of measures on LTCF pandemic preparedness for Covid-19 prevention. An improvement in infection control and mortality was detected between phases. Comments on sustainability High sustainability due to no new structures were created and a pragmatic approach reached. Comments on transferability High transferability due to the possibility of post-pandemic continuation of this collaborative networking, to build more integrated care in LTCF. Conclusions a. The more efficient strategy to reduce mortality was infection prevention. b. Using tests regularly for both residents and workers was key to detect all infected but asymptomatic patients. c. Defining risk factors for poor bad epidemiologic disease control at the facility level led to early preventive actions. Discussions All stakeholders assumed a unique strategy with shared objectives. Outbreak prevention, by detecting LTCF risks and avoiding spreading was key. An end-of-life focus emerged as a need, to provide right time right care palliative care to individuals with advanced illness and advanced care plans in this sense. Lessons learned This emergency response was an opportunity for re-thinking future integrated care LTCF approaches provided by several stakeholders. [ABSTRACT FROM AUTHOR]

Introduction: The growing numbers of People with Complex Chronic Conditions (PCCC) has been leading to a challenge of adaptation of the care providers' response to the high needs presented by individuals. Short description of practice change implemented: The creation of a Chronic Care Management Team (CCMT) supported an innovative strategy focused on reaching a more integrated model of care. A community-based care programme was developed based on: a. International evidence (reviewed by two CCMT experts); b. A consensus reached by clinical leaders involved on care (in a local task force group with 60 members from primary and secondary care); c. The inclusion of people experience (by two focus groups with patients, and home interviews to carers and members of community institutions). It led to a new organisational and governance model for the whole territory. An IT tools adaptation was required to support the CCMT task on monitoring the care process and outcome indicators. Aim and theory of change: In order to improve the quality of the care process and to obtain patientcentred outcomes in an efficient way, it was urged to change the usual model, to a new multidisciplinary, multidimensional, patient-centred provision of integrated care focused in the community, with the central role of expert Primary Care teams. Targeted population and stakeholders: PCCC including those with advanced illnesses. Stakeholders: several units from the Catalan Health Institute in Badalona area, North of Barcelona, as a territorial public provider of primary care and hospital care, which collaborate with other social care and intermediate care providers in the area. Timeline: Phase 1: development of theory for change (2018); Phase 2: implementation of the new model of care (2018-2019); Phase 3: evaluation of the model (2019). Highlights (innovation, Impact and outcomes) People-centred integrated care ongoing project at meso level as a response to high needs of PCCC in an urban territory in the Catalan public health system. Definition of the care model by people involved on care (patients, carers and staff). Functional integration of clinicians from the institution. CCMT led the integration by: defining and monitoring the quality of the care process, planning the adaptation of resources, and evaluating people-centred outcomes. Comments on sustainability: High sustainability expected due to the pragmatic approach. Comments on transferability: High transferability expected due to the position of our institution in the health system. Conclusions (comprising key findings): Our project was created based on a need to deepen on integrated care provision. Preliminary results on the quality of the care process have been evaluated. Preliminary results centred on people have been evaluated. Discussion: It is a huge opportunity for our system to develop and evaluate an integrated care strategy at a meso level, following the Catalan Government integrated care strategy. Lessons learned: Adapting the theoretical model to real world required a strong leadership, clear governance, time for change and the alignment of all the actors. The consensus reached, based on people experience and views, was a strong element for change. [ABSTRACT FROM AUTHOR]