The aim of this programme is to broaden our scientific understanding of the design of personalised care (care management for high-risk patients, integrated care for chronic patients, collaborative multidisciplinary programmes) in health care in the Basque Country and to evaluate the innovative methods and strategies that transform the organisation to provide better care to chronic patients. This programme includes research into integrated and multidisciplinary care.
Result: To create multidisciplinary teams covering different care levels that share information and diagnoses in a transparent manner. The study of new roles that will allow us to concentrate on improving the care and situation of patients by avoiding duplication and stopping performing low-added-value tasks.
List of Projects. Care continuum:
10. Planning health care in kidney failure patients in dialysis programmes.
15. Detection of variables that affect the chronicity process for severe mental illness.
20. ZAINDUZ: Application of chronic disease management models in primary care focussing on their integration into health care.
27. Psychiatric care of subjects with a mental disability in the Araba mental health network.
30. A collaborative project to improve the integrated approach to patients with depression in the Basque Country.
31. Analysis of the situation and proposal of an intervention to improve the management of Alzheimer’s disease in the Basque Country.
33. Improving the management and follow-up (effectiveness, quality of life and efficiency) of patients with diabetic foot by implementing a multidisciplinary diabetic foot unit. A prospective analysis.