Care models for polypathological patients | Revista Clínica Española

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Abbreviations: BNP, brain natriuretic peptide; V/P scintigraphy, ventilation/perfusion scintigraphy; NT-proBNP, amino-terminal fragment of BNP; PESI, Pulmonary Embolism Severity Index; PESIs, simplified PESI scale; RIETE, Computerized Registry of Patients with Venous Thromboembolism; CT, computed tomography; CTA, computer tomography angiography; PTE, pulmonary thromboembolism; DVT, deep vein thrombosis; RV, right ventricle. Source: Adapted from Konstantinides et al.<a class="elsevierStyleCrossRef" href="#bib0425">8</a> and modified by the authors." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Maestre Peiró, A. Gonzálvez Gasch, M. Monreal Bosch" "autores" => array:3 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Maestre Peiró" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Gonzálvez Gasch" ] 2 => array:2 [ "nombre" => "M." 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Polypathology" "titulo" => "Care models for polypathological patients" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "351" "paginaFinal" => "358" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Fernández Moyano, J.M. Machín Lázaro, M.D. Martín Escalante, M.B. Aller Hernandez, I. Vallejo Maroto" "autores" => array:5 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Fernández Moyano" "email" => array:1 [ 0 => "antonio.fernandez@sjd.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.M." "apellidos" => "Machín Lázaro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M.D." "apellidos" => "Martín Escalante" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M.B." "apellidos" => "Aller Hernandez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "I." "apellidos" => "Vallejo Maroto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Continuidad Asistencial Primaria-Interna (UCAPI), Servicio de Medicina Interna, Hospital Universitario de Guadalajara, Guadalajara, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Medicina Interna, Agencia Pública Sanitaria Costa del Sol, Hospital Costa del Sol, Marbella, Málaga, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Grup de Recerca en Polítiques de Salut i Serveis Sanitaris, Servei d’Estudis i Prospectives en Polítiques de Salut, Consorci de Salut i Social de Catalunya, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Modelos de atención al paciente pluripatológico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Innovative care for chronic conditions: organization and delivery of high-quality care of noncommunicable chronic diseases in the Americas." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1120 "Ancho" => 2498 "Tamanyo" => 162675 ] ] "descripcion" => array:1 [ "en" => "The care model for patients with chronic diseases." ] ] ] "textoCompleto" => "BackgroundPolypathological patients experience multiple chronic diseases, which are generally interrelated but with none taking a central role, sharing equal complexity and the capacity for destabilization.<a class="elsevierStyleCrossRefs" href="#bib0325">1,2</a> These patients also have common characteristics such as advanced age, frailty and frequent decompensations, which usually require health care, including hospitalization. These patients frequently have progressive functional impairment, a high degree of dependence (which affects their social environment), high mortality and greater resource consumption.<a class="elsevierStyleCrossRefs" href="#bib0325">1,2</a>In recent decades, the progressive improvements in the healthcare conditions of countries in the Organization for Economic Cooperation and Development (OECD) has helped prolong the survival of these patients but has also extended the period of disability. Chronic diseases accumulate in an individual as they age, with an average of more than 4 diseases after the age of 80 years.<a class="elsevierStyleCrossRef" href="#bib0335">3</a> Due to their greater demand for care, polypathological patients more often feel the effects of interlevel fragmentation in healthcare systems. Research in this area has focused on the clinical, epidemiological and prognostic characterization<a class="elsevierStyleCrossRefs" href="#bib0340">4–6</a> and on the assessment of the public health impact.<a class="elsevierStyleCrossRef" href="#bib0355">7</a>The current healthcare models are the fruit of the predominant healthcare planning of the 1990s,<a class="elsevierStyleCrossRef" href="#bib0360">8</a> aimed at the care of acute diseases. These models propose the separation of objectives, responsibilities and budgets within the healthcare system. The scarce coordination in healthcare is therefore apparent, particularly for patients with chronic diseases. In this old model, the “typology of patients” resulted in reduced accessibility to needed healthcare services, intralevel and interlevel incoordination, more specialties involvement in the care, increased hospital visits, increased probability of test duplication, lack of treatment reconciliation, increased risk of interactions and adverse events and a lack of healthcare continuity on admission or after hospitalization. These healthcare models also fail to sufficiently consider healthcare promotion strategies and do not consider the patient's values and preferences.In short, the way in which patients get sick has changed,<a class="elsevierStyleCrossRef" href="#bib0365">9</a> and polypathological patients have been a healthcare problem in our present society. Although advances are being made in these patients’ epidemiology and healthcare needs, healthcare models with demonstrated efficacy<a class="elsevierStyleCrossRefs" href="#bib0370">10–12</a> need to be implemented for these patients, given the present fragmented system of care, prescription and communication.General characteristics of the healthcare models for chronic diseasesThe most widespread and assessed healthcare model is the Chronic Care Model (CCM) developed by the MacColl Institute for Healthcare Innovation of Seattle,<a class="elsevierStyleCrossRef" href="#bib0385">13</a> along with the two subsequent adaptations: the Expanded Chronic Care Model (ECCM), developed by the Government of the British Columbia of Canada,<a class="elsevierStyleCrossRef" href="#bib0390">14</a> and the Innovative Care for Chronic Conditions (ICCC) of the World Health Organization.<a class="elsevierStyleCrossRef" href="#bib0395">15</a>These models are constructed with various components that are essential to providing optimal care to chronically ill patients, which refer to the healthcare system, to the healthcare organization and to the community (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>In terms of healthcare organization, four interdependent components have been identified<a class="elsevierStyleCrossRef" href="#bib0385">13</a>: (1) the design for the system for providing care, focusing on team work through the joint use of resources and the collaboration among hospital and primary care practitioners; (2) the support of self-care, through educational resources and psychosocial support, as a reflection of the patient's central role in managing their care; (3) decision making support, by introducing tools that provide care based on good clinical practices; and (4) the development of information systems that help practitioners share the patients’ clinical information and identify those subgroups that require more proactive care.The model's purpose is to create an appropriate environment for productive interactions between patients and healthcare practitioners. The CCM focuses mainly on the organization of healthcare and scarcely treats the aspects of community, prevention and health promotion.<a class="elsevierStyleCrossRefs" href="#bib0390">14,16</a> Subsequent adaptations of the model have therefore focused on developing these components,<a class="elsevierStyleCrossRefs" href="#bib0390">14,15</a> without introducing significant changes in the components of the setting of healthcare organization.All elements of the system described in the CCM have been designed to support the development of ready and proactive healthcare teams and an informed and active patient population. A prepared health team entails having the skills, information and resources necessary for ensuring effective clinical management and having ready access to the teams, supplies and drugs necessary to provide evidence-based care. A proactive health team involves the capacity for anticipating the patients’ needs, preventing diseases and complications by reducing risk factors and planning care in a manner that does not depend on acute exacerbations or symptoms as the only trigger for clinical encounters. An informed and active patient has the information, education, motivation and confidence to conduct their self-care. The central role of this association between providers and patients is a substantial change in the traditional forms of healthcare organization and delivery. This model is more effective when patients and health professionals are equal partners and experts in their own domains: the physicians and nurses in terms of the clinical management of the disease, and the patients with regard to their experience with the disease, their needs and preferences.<a class="elsevierStyleCrossRef" href="#bib0405">17</a>Care models for polypathological patientsIn December 2010, The Council of the European Union established as a priority the development of action plans to decrease the impact of chronic diseases. The Council requested that its member states implement specific and coordinated measures aimed at promoting health, prevention, treatment and care for chronic diseases.<a class="elsevierStyleCrossRef" href="#bib0410">18</a> In 2011, the United Nations Organization formulated the Declaration on the Prevention and Control of Noncommunicable Chronic Diseases,<a class="elsevierStyleCrossRef" href="#bib0415">19</a> which, among other issues, urged the inclusion of prevention for these diseases as a priority in all national and international programs. The most relevant plans are described below.International modelsChronicity care plans in the European UnionIn 2015, the results were published on the Joint Action on Chronic Diseases and Promoting Healthy Aging across the Life Cycle (JA-CHRODIS),<a class="elsevierStyleCrossRef" href="#bib0420">20</a> sponsored by the health authorities of the member states of the European Union. The study analyzed the characteristics of 119 chronicity care programs in European countries, 22 of which were Spanish. The common characteristics of these programs are as follows: patient-focused; emphasis placed on healthcare coordination; facilitates caregiver collaboration (multidisciplinary); results-focused; involves various disciplines (practitioner and caregiver) and government organizations; includes practitioner profiles such as that of case manager; and addresses polypharmacy and therapeutic compliance. A number of the programs specifically focus on frail elderly patients.Of the 119 European programs on chronicity, 101 were defined as integrated care programs for patients with multimorbidity. Of these, 58% were directed to patients with multimorbidity in general, while 33% were implemented for patients with comorbidities associated with a primary diagnosis (index disease), the most common of which were type 2 diabetes, chronic obstructive pulmonary disease and heart failure. Lastly, 9% of the programs were specifically focused on frail elderly patients. The main objective differed according to the care program, but the most common objective was to increase multidisciplinary collaboration.Other chronicity care plans in countries of the European UnionUnited KingdomWithin the High-Quality Care For All strategy of the National Health Service, various pilot projects for healthcare integration have been developed since 2008, including the Kaiser model.<a class="elsevierStyleCrossRef" href="#bib0425">21</a> The success of this latter model is based on risk-based patient stratification and combining prevention, support for self-management (through information, educational and training programs), disease management and the management of highly complex cases. The model includes healthcare integration, enabling patients to be easily moved between hospitals and the community, so that hospital physicians and primary care physicians can work together and not develop competing parallel activities or structures. The model promotes active patient management in the hospital and includes the use of common treatment protocols. An appropriate level of care is applied for each necessity, such as specialist centers that provide rehabilitation for patients who do not need to be in acute hospitals but are also not suitable for going home. All of this is backed by powerful information technology. For example, the Health Connect program helps members to communicate through e-mail, access the medical history, arrange medical appointments and manage prescriptions.PACE Model (Program of All-inclusive Care for the Elderly)<a class="elsevierStyleCrossRef" href="#bib0430">22</a>This program is implemented in the United States to provide comprehensive care for patients older than 55 years who are in a situation of vulnerability. The program has 2 main characteristics. Firstly, the care is conducted by a multidisciplinary team (physicians, nurses, physiotherapists, social workers, etc.) responsible for 100% of the services that users require (primary and specialized medical care, nursing, social services, occupational therapy, physical therapy, language therapy, leisure, pharmacy, home care, etc.) and planning the healthcare in conjunction with the user and their family. Secondly, the program develops activities for improving functionality and disease control at home.SIPA Model (Évaluation du Système Intégré pour Personnes Âgées frágiles)<a class="elsevierStyleCrossRef" href="#bib0435">23</a>This program is implemented in Montreal and is targeted to patients over 65 years of age who are frail and live at home. SIPA establishes a model of coordination among hospitals, nursing homes, rehabilitation centers and community service centers of Montreal. The work team is composed of nurses, social workers, occupational therapists, physiotherapists and nutritionists. The nurses, social workers and occupational therapists assume the role of case managers who must ensure the collaboration of all those involved; in particular, maintaining close contact with the family doctor and following patients during their stay in the hospital, emergency departments and adult day care centers.PRISMA Model (Program of Research to Integrate the Services for the Maintenance of Autonomy)<a class="elsevierStyleCrossRef" href="#bib0440">24</a>This model is implemented in the province of Quebec and is targeted to patients older than 65 years with moderate to severe dependence who need two or more healthcare or social services and who can remain at home. The model has two relevant characteristics: (1) coordination at all levels of the organization, including healthcare, social and community organizations, at both the micro and meso-level of management and (2) the activity of case manager who evaluates, plans, organizes and leads the multidisciplinary team, designing an individualized service plan and using functional autonomy as the main assessment instrument.National modelsIn consideration of the proposals of the Declaration of Seville<a class="elsevierStyleCrossRef" href="#bib0445">25</a> and the Strategy for Addressing Chronicity in the Spanish National Health System,<a class="elsevierStyleCrossRef" href="#bib0450">26</a> various strategic plans have been developed in each autonomous community (AC) of Spain. There are currently chronicity care programs in 15 of the 17 CAs,<a class="elsevierStyleCrossRefs" href="#bib0455">27–41</a> with the exception of Ceuta and Melilla whose plans have not been published (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The following elements are common to all of the programs: (1) an analysis of the demographic and epidemiological situation using health surveys of the CA itself or from the Spanish National Institute of Statistics; (2) an analysis of the healthcare activity, both in primary care and in hospital (outpatient and hospitalization processes, minimum basic data set, adjusted average length of stay index, emergency department care in the last year, etc.); (3) the identification of vulnerability, by analyzing resource consumption (prescription), polypharmacy and attendance in consultations and emergency departments; (4) risk stratification, primarily using the Kaiser Permanente pyramid,<a class="elsevierStyleCrossRef" href="#bib0425">21</a> with three levels of risk (low, medium and high) that require differentiated services, adjusted to the characteristics and needs of each stratum; and (5) elements of continuity of care. Most of the AC strategies emphasize the electronic medical history shared among the various healthcare levels and the roles of nursing liaisons and specialist physician consultants.With these elements, the strategies seek to provide primary care practitioners with direct, personalized and actual support for managing patients with complex chronic disease, helping practitioners maintain coordinated care for each patient. The strategies also seek to keep the same team for the patient while in the hospital, promoting joint meetings and shared understanding among practitioners.The implementation of new chronicity care models in each AC has boosted existing resources and generated new professional profiles and training (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Evaluation of the programsThe assessment of the health results from these programs facilitates decision making in healthcare policy on the management of individuals with multiple diseases and multimorbidity. Although the evidence supporting these programs is increasing, it is still low to moderate. The assessments show weakness in the internal validity and broad variability in the external validity and in the magnitude of its effects. This low-quality of evidence is due, among others, to 3 determinants. Firstly, the study designs vary from the randomized clinical study (RCS) to the cluster-RCS, quasi-RCS, pre-postintervention studies and simply descriptive postintervention studies, which limit the internal validity. The wide clinical and prognostic variability of the populations included in the studies determine the comparability of the results. Secondly, the designs vary significantly in the number, type and development of the interventions performed within the 6 generic areas of the CCM/ECCM,<a class="elsevierStyleCrossRef" href="#bib0535">43</a> which hinders the identification and comparison of the effective interventions. Lastly, the assessment of results is not standardized in terms of the variables and measurement tools. The variables are not very objective and are grouped predominantly into health results (satisfaction, quality of life, depressive symptoms, functionality and mortality), process results (use of community, primary care and hospital services, including the number of consultations, mean stay, sum stays of hospital and readmissions) and cost results (for the hospital, primary care or both).With the available data and considering the difficulty of the methodological determinants described, it is still not possible to reach firm conclusions on the overall efficiency of the integral care programs for patients with multimorbidity. It does appear that the models that develop comprehensive care improve patient satisfaction, quality of life and functional state, although the evidence is weak.<a class="elsevierStyleCrossRefs" href="#bib0380">12,44</a> There is insufficient evidence to ensure that the models reduce costs and the use of services.A recent Cochrane review<a class="elsevierStyleCrossRef" href="#bib0380">12</a> and the systematic review by Hopman et al.<a class="elsevierStyleCrossRef" href="#bib0540">44</a> analyzed a total of 34 studies (23 RCS, 5 pretest–posttest studies, 3 cluster-RCS, 2 posttest studies and 1 quasi-ACS), of which 18 were considered high or relatively high quality. All of the studies were aimed at assessing the implementation of comprehensive programs for patients with multimorbidity. Ahn et al.<a class="elsevierStyleCrossRef" href="#bib0545">45</a> conducted a “before and after” study with 825 participants from 22 organizations in 17 US states. Through the fundamental intervention of improvement in self-care with a structured program (Chronic Disease Self-Management Program), the authors found a reduction in emergency department visits at 6 and 12 months (odds ratio [OR] of 0.68 and 0.7, respectively) and hospital admissions at 6 months (OR, 0.7). The mean cost reduction per patient was $713. Similar findings were found by Weber et al.,<a class="elsevierStyleCrossRef" href="#bib0550">46</a> while Levine et al.<a class="elsevierStyleCrossRef" href="#bib0555">47</a> reported no differences in costs. Kono et al.<a class="elsevierStyleCrossRef" href="#bib0560">48</a> even reported an increase in costs. An RCS in the San Francisco area<a class="elsevierStyleCrossRef" href="#bib0565">49</a> assessed the impact of the Seniors Care Connection program on 280 patients with multimorbidity in the intervention group. The intervention was conducted by a primary care-focused team, consisting of a physician, a nurse and a social worker, with specific training in chronic diseases, and telephone calls and home visits at least once every 6 weeks for 2 years. The study showed a reduction in the number of admissions per patient per year (0.36 vs. 0.52) and in the frequency of readmissions at 2 months (3.6% vs. 9.4%), which resulted in a cost reduction of $90 per patient. Another high-quality RCS<a class="elsevierStyleCrossRef" href="#bib0555">47</a> was subsequently published and included an intervention group of 156 patients with multimorbidity from 3 counties in Los Angeles. The study assessed the effect of the Choices for Healthy Aging care program (which included 5 areas of performance of the CCM) by conducting a 12-month follow-up. In the intervention group, the likelihood of hospital admission was lowered (25.6% vs. 37.1%, p=0.02). The study also found increased satisfaction with the care, with no differences in terms of costs. Of the previously mentioned high-quality studies, nine found no notable benefits in the use of healthcare services.<a class="elsevierStyleCrossRefs" href="#bib0550">46,48,50–56</a> In terms of functionality, three studies<a class="elsevierStyleCrossRefs" href="#bib0605">57–59</a> found an improvement in daily life activities, while four others found no differences.<a class="elsevierStyleCrossRefs" href="#bib0560">48,50,51,60</a> Recently, in our healthcare community, Lanzeta et al.<a class="elsevierStyleCrossRef" href="#bib0625">61</a> conducted an RCS on an intervention group of 70 polypathological patients from the Goierri-Alto Urola healthcare district, who were hospitalized at least once the previous year. The intervention included activities in four areas of the CCM, and the patients were treated by a physician and a primary care nurse, with the support of a reference internist and a nurse liaison, conducting a comprehensive assessment and health education. The intervention scheduled in the study was no more efficient than the standard healthcare. However, the statistical analysis revealed that in the patient subgroup younger than 80 years and with at least three clinical categories defining polypathological patients, the intervention achieved cost reductions in 89% of the simulations, although the differences were not significant. The simulation consisted of a statistical exercise that helped estimate the effect of an intervention on an imaginary population that mimicked the actual population group for which the intervention was to be performed on. The authors interpreted these results assuming that the changes previously introduced in the healthcare organization and in the clinical management could have changed the polypathological patients’ natural history, improving their prognosis. This could justify the absence of significant positive results in the study interventions.<a class="elsevierStyleCrossRef" href="#bib0625">61</a> The data support the need to identify patient subgroups who can benefit from the interventions.Considering the current difficulty in decision making, it would be useful to improve 3 aspects of the healthcare programs directed at polypathological patients. Firstly, the chosen design should provide evidence in those conditions in which an experimental approach is not possible. Choosing the so-called “natural experiment” could help,<a class="elsevierStyleCrossRef" href="#bib0630">62</a> which includes all individuals with a clinical condition that is the object of intervention (in this case, polypathological patients), although this is not completely applied to all patients who meet the condition being studied. Secondly, the coordination of the interventions on polypathological patients should be improved. We need to develop, in the European setting, an observatory that acts as a platform for exchanging knowledge and that helps identify, validate, exchange and spread the good practices on chronic diseases from member states of the European Union. Along this line, experience is being gained from JA-CHRODIS,<a class="elsevierStyleCrossRef" href="#bib0635">63</a> which is expected to meet this objective. Finally, in the development and assessment of the programs, we need to promote the common elements that improve external validity, adapting them to the specific characteristics of each country's healthcare policy.In short, the prevalence of chronic diseases has changed the way in which the population gets ill. The proposed healthcare models have implemented activities aimed at addressing the needs of these patients, probably achieving improved patient satisfaction, quality of life and functional condition. Healthcare organizations should continue to smoothly transform themselves to answer this new healthcare challenge.<a class="elsevierStyleCrossRef" href="#bib0640">64</a> We also need to define which sector of patients and in what type of interventions the most relevant benefits are produced.Conflict of interestsThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres875321" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec863515" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres875320" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec863516" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "General characteristics of the healthcare models for chronic diseases" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Care models for polypathological patients" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "International models" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Chronicity care plans in the European Union" ] 1 => array:3 [ "identificador" => "sec0030" "titulo" => "Other chronicity care plans in countries of the European Union" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "United Kingdom" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "PACE Model (Program of All-inclusive Care for the Elderly)" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "SIPA Model (Évaluation du Système Intégré pour Personnes Âgées frágiles)" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "PRISMA Model (Program of Research to Integrate the Services for the Maintenance of Autonomy)" ] ] ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "National models" ] ] ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Evaluation of the programs" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-02-11" "fechaAceptado" => "2017-03-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec863515" "palabras" => array:4 [ 0 => "Polypathology" 1 => "Chronic diseases" 2 => "Healthcare models" 3 => "Health results" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec863516" "palabras" => array:4 [ 0 => "Pluripatología" 1 => "Enfermedades crónicas" 2 => "Modelos asistenciales" 3 => "Resultados en salud" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Polypathological patients have specific clinical, functional, psychoaffective, social, family and spiritual characteristics. These patients are generally elderly and frail and have frequent decompensations. They frequently use healthcare resources, have significant functional impairment and have a high index of dependence. This results in a significant social impact, high mortality and a high consumption of resources. The current healthcare models have not answered these needs, which causes problems with accessibility to healthcare services, a lack of coordination among these services, a higher probability of adverse events related to polypharmacy and a high consumption of resources. In the past decade, the healthcare models have changed and are characterized by work in multidisciplinary and interlevel teams, patient self-care, the availability of tools for decision making, information and communication systems and prevention. The goal is to have prepared and proactive health teams and an informed and active patient population. The assessment of health results, processes and the costs for these programs is still based on moderate to low evidence. It is therefore not an easy task to determine the type and intensity of interventions or to determine the patient groups that could gain more benefits." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Los pacientes pluripatológicos tienen unas características clínicas, funcionales, psicoafectivas, sociofamiliares y espirituales específicas. Son generalmente de edad avanzada, frágiles, con frecuentes descompensaciones, uso frecuente de recursos sanitarios, deterioro funcional importante y un elevado índice de dependencia; de lo que se deriva un importante impacto social, mortalidad elevada y consumo de recursos. Los modelos asistenciales actuales no han dado respuesta a estas necesidades, lo que produce problemas en la accesibilidad a los servicios sanitarios, descoordinación entre estos, mayor probabilidad de eventos adversos relacionados con la polimedicación y un alto consumo de recursos. En la última década, los modelos asistenciales están cambiando y se caracterizan por el trabajo en equipo multidisciplinar e interniveles, el autocuidado del paciente, la disponibilidad de herramientas para la toma de decisiones, los sistemas de información y comunicación y la prevención. Se pretende conseguir un equipo de salud preparado y proactivo y una población de pacientes informados y activados. La evaluación de los resultados en salud, procesos y costes de estos programas, se apoya todavía en evidencias moderadas o bajas. Por ello, no es fácil determinar el tipo e intensidad de las intervenciones, ni los grupos de pacientes sobre los que pueden aportar más beneficios." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Fernández Moyano A, Machín Lázaro JM, Martín Escalante MD, Aller Hernandez MB, Vallejo Maroto I. Modelos de atención al paciente pluripatológico. Rev Clin Esp. 2017;217:351–358." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Innovative care for chronic conditions: organization and delivery of high-quality care of noncommunicable chronic diseases in the Americas." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1120 "Ancho" => 2498 "Tamanyo" => 162675 ] ] "descripcion" => array:1 [ "en" => "The care model for patients with chronic diseases." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Source: adapted from García-Gonzálvez.<a class="elsevierStyleCrossRef" href="#bib0530">42</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year of legal deposit \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Health Promotion \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Disease prevention and limitations \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Continuity of care \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Healthcare reorientation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Research and innovation \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aragon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2006 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Basque Country \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Andalusia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Castilla-León \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Murcia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Navarra \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Madrid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C. of Valencia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asturias \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">La Rioja \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Galicia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Canary Islands \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cantabria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Castilla-La Mancha \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Catalonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1477439.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Relationship between the lines proposed by the Spanish National System of Health and its inclusion in the guidelines of the autonomous communities." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Advanced nursing competencies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• School of patients or active or expert patient-caregiver \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Unified electronic medical history \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Electronic prescription \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Multichannel health department centers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Hospital units for subacute patients or medium stay \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Home hospitalization units \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Health portal or personal health folder \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Hospital units for acute patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Specific programs or units for polypathological patients \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1477440.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Relationship of the most common activities (resources, practitioner profiles and activities) of the various care models." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:64 [ 0 => array:3 [ "identificador" => "bib0325" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patient-centered care for older adults with multiple chronic conditions: these are the polypathological patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. 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Symposium. Polypathology

Care models for polypathological patients

Modelos de atención al paciente pluripatológico

A. Fernández Moyanoa,

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antonio.fernandez@sjd.es

Corresponding author.

, J.M. Machín Lázarob, M.D. Martín Escalantec, M.B. Aller Hernandezd, I. Vallejo Marotoa

a Servicio de Medicina Interna, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, Spain

b Unidad de Continuidad Asistencial Primaria-Interna (UCAPI), Servicio de Medicina Interna, Hospital Universitario de Guadalajara, Guadalajara, Spain

c Unidad de Medicina Interna, Agencia Pública Sanitaria Costa del Sol, Hospital Costa del Sol, Marbella, Málaga, Spain

d Grup de Recerca en Polítiques de Salut i Serveis Sanitaris, Servei d’Estudis i Prospectives en Polítiques de Salut, Consorci de Salut i Social de Catalunya, Barcelona, Spain

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These models propose the separation of objectives&#44; responsibilities and budgets within the healthcare system&#46; The scarce coordination in healthcare is therefore apparent&#44; particularly for patients with chronic diseases&#46; In this old model&#44; the &#8220;typology of patients&#8221; resulted in reduced accessibility to needed healthcare services&#44; intralevel and interlevel incoordination&#44; more specialties involvement in the care&#44; increased hospital visits&#44; increased probability of test duplication&#44; lack of treatment reconciliation&#44; increased risk of interactions and adverse events and a lack of healthcare continuity on admission or after hospitalization&#46; These healthcare models also fail to sufficiently consider healthcare promotion strategies and do not consider the patient&#39;s values and preferences&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In short&#44; the way in which patients get sick has changed&#44;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">9</span></a> and polypathological patients have been a healthcare problem in our present society&#46; 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of the World Health Organization&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">These models are constructed with various components that are essential to providing optimal care to chronically ill patients&#44; which refer to the healthcare system&#44; to the healthcare organization and to the community &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In terms of healthcare organization&#44; four interdependent components have been identified<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">13</span></a>&#58; &#40;1&#41; the design for the system for providing care&#44; focusing on team work through the joint use of resources and the collaboration among hospital and primary care practitioners&#59; &#40;2&#41; the support of self-care&#44; through educational resources and psychosocial support&#44; as a reflection of the patient&#39;s central role in managing their care&#59; &#40;3&#41; decision making support&#44; by introducing tools that provide care based on good clinical practices&#59; and &#40;4&#41; the development of information systems that help practitioners share the patients&#8217; clinical information and identify those subgroups that require more proactive care&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The model&#39;s purpose is to create an appropriate environment for productive interactions between patients and healthcare practitioners&#46; The CCM focuses mainly on the organization of healthcare and scarcely treats the aspects of community&#44; prevention and health promotion&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">14&#44;16</span></a> Subsequent adaptations of the model have therefore focused on developing these components&#44;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">14&#44;15</span></a> without introducing significant changes in the components of the setting of healthcare organization&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">All elements of the system described in the CCM have been designed to support the development of ready and proactive healthcare teams and an informed and active patient population&#46; A prepared health team entails having the skills&#44; information and resources necessary for ensuring effective clinical management and having ready access to the teams&#44; supplies and drugs necessary to provide evidence-based care&#46; A proactive health team involves the capacity for anticipating the patients&#8217; needs&#44; preventing diseases and complications by reducing risk factors and planning care in a manner that does not depend on acute exacerbations or symptoms as the only trigger for clinical encounters&#46; An informed and active patient has the information&#44; education&#44; motivation and confidence to conduct their self-care&#46; The central role of this association between providers and patients is a substantial change in the traditional forms of healthcare organization and delivery&#46; This model is more effective when patients and health professionals are equal partners and experts in their own domains&#58; the physicians and nurses in terms of the clinical management of the disease&#44; and the patients with regard to their experience with the disease&#44; their needs and preferences&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Care models for polypathological patients</span><p id="par0050" class="elsevierStylePara elsevierViewall">In December 2010&#44; The Council of the European Union established as a priority the development of action plans to decrease the impact of chronic diseases&#46; The Council requested that its member states implement specific and coordinated measures aimed at promoting health&#44; prevention&#44; treatment and care for chronic diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">18</span></a> In 2011&#44; the United Nations Organization formulated the Declaration on the Prevention and Control of Noncommunicable Chronic Diseases&#44;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">19</span></a> which&#44; among other issues&#44; urged the inclusion of prevention for these diseases as a priority in all national and international programs&#46; The most relevant plans are described below&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">International models</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Chronicity care plans in the European Union</span><p id="par0055" class="elsevierStylePara elsevierViewall">In 2015&#44; the results were published on the Joint Action on Chronic Diseases and Promoting Healthy Aging across the Life Cycle &#40;JA-CHRODIS&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">20</span></a> sponsored by the health authorities of the member states of the European Union&#46; The study analyzed the characteristics of 119 chronicity care programs in European countries&#44; 22 of which were Spanish&#46; The common characteristics of these programs are as follows&#58; patient-focused&#59; emphasis placed on healthcare coordination&#59; facilitates caregiver collaboration &#40;multidisciplinary&#41;&#59; results-focused&#59; involves various disciplines &#40;practitioner and caregiver&#41; and government organizations&#59; includes practitioner profiles such as that of case manager&#59; and addresses polypharmacy and therapeutic compliance&#46; A number of the programs specifically focus on frail elderly patients&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Of the 119 European programs on chronicity&#44; 101 were defined as integrated care programs for patients with multimorbidity&#46; Of these&#44; 58&#37; were directed to patients with multimorbidity in general&#44; while 33&#37; were implemented for patients with comorbidities associated with a primary diagnosis &#40;index disease&#41;&#44; the most common of which were type 2 diabetes&#44; chronic obstructive pulmonary disease and heart failure&#46; Lastly&#44; 9&#37; of the programs were specifically focused on frail elderly patients&#46; The main objective differed according to the care program&#44; but the most common objective was to increase multidisciplinary collaboration&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Other chronicity care plans in countries of the European Union</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">United Kingdom</span><p id="par0065" class="elsevierStylePara elsevierViewall">Within the High-Quality Care For All strategy of the National Health Service&#44; various pilot projects for healthcare integration have been developed since 2008&#44; including the Kaiser model&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">21</span></a> The success of this latter model is based on risk-based patient stratification and combining prevention&#44; support for self-management &#40;through information&#44; educational and training programs&#41;&#44; disease management and the management of highly complex cases&#46; The model includes healthcare integration&#44; enabling patients to be easily moved between hospitals and the community&#44; so that hospital physicians and primary care physicians can work together and not develop competing parallel activities or structures&#46; The model promotes active patient management in the hospital and includes the use of common treatment protocols&#46; An appropriate level of care is applied for each necessity&#44; such as specialist centers that provide rehabilitation for patients who do not need to be in acute hospitals but are also not suitable for going home&#46; All of this is backed by powerful information technology&#46; For example&#44; the Health Connect program helps members to communicate through e-mail&#44; access the medical history&#44; arrange medical appointments and manage prescriptions&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">PACE Model &#40;Program of All-inclusive Care for the Elderly&#41;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">22</span></a></span><p id="par0070" class="elsevierStylePara elsevierViewall">This program is implemented in the United States to provide comprehensive care for patients older than 55 years who are in a situation of vulnerability&#46; The program has 2 main characteristics&#46; Firstly&#44; the care is conducted by a multidisciplinary team &#40;physicians&#44; nurses&#44; physiotherapists&#44; social workers&#44; etc&#46;&#41; responsible for 100&#37; of the services that users require &#40;primary and specialized medical care&#44; nursing&#44; social services&#44; occupational therapy&#44; physical therapy&#44; language therapy&#44; leisure&#44; pharmacy&#44; home care&#44; etc&#46;&#41; and planning the healthcare in conjunction with the user and their family&#46; Secondly&#44; the program develops activities for improving functionality and disease control at home&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">SIPA Model &#40;&#201;valuation du Syst&#232;me Int&#233;gr&#233; pour Personnes &#194;g&#233;es fr&#225;giles&#41;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">23</span></a></span><p id="par0075" class="elsevierStylePara elsevierViewall">This program is implemented in Montreal and is targeted to patients over 65 years of age who are frail and live at home&#46; SIPA establishes a model of coordination among hospitals&#44; nursing homes&#44; rehabilitation centers and community service centers of Montreal&#46; The work team is composed of nurses&#44; social workers&#44; occupational therapists&#44; physiotherapists and nutritionists&#46; The nurses&#44; social workers and occupational therapists assume the role of case managers who must ensure the collaboration of all those involved&#59; in particular&#44; maintaining close contact with the family doctor and following patients during their stay in the hospital&#44; emergency departments and adult day care centers&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">PRISMA Model &#40;Program of Research to Integrate the Services for the Maintenance of Autonomy&#41;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">24</span></a></span><p id="par0080" class="elsevierStylePara elsevierViewall">This model is implemented in the province of Quebec and is targeted to patients older than 65 years with moderate to severe dependence who need two or more healthcare or social services and who can remain at home&#46; The model has two relevant characteristics&#58; &#40;1&#41; coordination at all levels of the organization&#44; including healthcare&#44; social and community organizations&#44; at both the micro and meso-level of management and &#40;2&#41; the activity of case manager who evaluates&#44; plans&#44; organizes and leads the multidisciplinary team&#44; designing an individualized service plan and using functional autonomy as the main assessment instrument&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">National models</span><p id="par0085" class="elsevierStylePara elsevierViewall">In consideration of the proposals of the Declaration of Seville<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">25</span></a> and the Strategy for Addressing Chronicity in the Spanish National Health System&#44;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">26</span></a> various strategic plans have been developed in each autonomous community &#40;AC&#41; of Spain&#46; There are currently chronicity care programs in 15 of the 17 CAs&#44;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">27&#8211;41</span></a> with the exception of Ceuta and Melilla whose plans have not been published &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The following elements are common to all of the programs&#58; &#40;1&#41; an analysis of the demographic and epidemiological situation using health surveys of the CA itself or from the Spanish National Institute of Statistics&#59; &#40;2&#41; an analysis of the healthcare activity&#44; both in primary care and in hospital &#40;outpatient and hospitalization processes&#44; minimum basic data set&#44; adjusted average length of stay index&#44; emergency department care in the last year&#44; etc&#46;&#41;&#59; &#40;3&#41; the identification of vulnerability&#44; by analyzing resource consumption &#40;prescription&#41;&#44; polypharmacy and attendance in consultations and emergency departments&#59; &#40;4&#41; risk stratification&#44; primarily using the Kaiser Permanente pyramid&#44;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">21</span></a> with three levels of risk &#40;low&#44; medium and high&#41; that require differentiated services&#44; adjusted to the characteristics and needs of each stratum&#59; and &#40;5&#41; elements of continuity of care&#46; Most of the AC strategies emphasize the electronic medical history shared among the various healthcare levels and the roles of nursing liaisons and specialist physician consultants&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">With these elements&#44; the strategies seek to provide primary care practitioners with direct&#44; personalized and actual support for managing patients with complex chronic disease&#44; helping practitioners maintain coordinated care for each patient&#46; The strategies also seek to keep the same team for the patient while in the hospital&#44; promoting joint meetings and shared understanding among practitioners&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The implementation of new chronicity care models in each AC has boosted existing resources and generated new professional profiles and training &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Evaluation of the programs</span><p id="par0105" class="elsevierStylePara elsevierViewall">The assessment of the health results from these programs facilitates decision making in healthcare policy on the management of individuals with multiple diseases and multimorbidity&#46; Although the evidence supporting these programs is increasing&#44; it is still low to moderate&#46; The assessments show weakness in the internal validity and broad variability in the external validity and in the magnitude of its effects&#46; This low-quality of evidence is due&#44; among others&#44; to 3 determinants&#46; Firstly&#44; the study designs vary from the randomized clinical study &#40;RCS&#41; to the cluster-RCS&#44; quasi-RCS&#44; pre-postintervention studies and simply descriptive postintervention studies&#44; which limit the internal validity&#46; The wide clinical and prognostic variability of the populations included in the studies determine the comparability of the results&#46; Secondly&#44; the designs vary significantly in the number&#44; type and development of the interventions performed within the 6 generic areas of the CCM&#47;ECCM&#44;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">43</span></a> which hinders the identification and comparison of the effective interventions&#46; Lastly&#44; the assessment of results is not standardized in terms of the variables and measurement tools&#46; The variables are not very objective and are grouped predominantly into health results &#40;satisfaction&#44; quality of life&#44; depressive symptoms&#44; functionality and mortality&#41;&#44; process results &#40;use of community&#44; primary care and hospital services&#44; including the number of consultations&#44; mean stay&#44; sum stays of hospital and readmissions&#41; and cost results &#40;for the hospital&#44; primary care or both&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">With the available data and considering the difficulty of the methodological determinants described&#44; it is still not possible to reach firm conclusions on the overall efficiency of the integral care programs for patients with multimorbidity&#46; It does appear that the models that develop comprehensive care improve patient satisfaction&#44; quality of life and functional state&#44; although the evidence is weak&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">12&#44;44</span></a> There is insufficient evidence to ensure that the models reduce costs and the use of services&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A recent Cochrane review<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">12</span></a> and the systematic review by Hopman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">44</span></a> analyzed a total of 34 studies &#40;23 RCS&#44; 5 pretest&#8211;posttest studies&#44; 3 cluster-RCS&#44; 2 posttest studies and 1 quasi-ACS&#41;&#44; of which 18 were considered high or relatively high quality&#46; All of the studies were aimed at assessing the implementation of comprehensive programs for patients with multimorbidity&#46; Ahn et al&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">45</span></a> conducted a &#8220;before and after&#8221; study with 825 participants from 22 organizations in 17 US states&#46; Through the fundamental intervention of improvement in self-care with a structured program &#40;Chronic Disease Self-Management Program&#41;&#44; the authors found a reduction in emergency department visits at 6 and 12 months &#40;odds ratio &#91;OR&#93; of 0&#46;68 and 0&#46;7&#44; respectively&#41; and hospital admissions at 6 months &#40;OR&#44; 0&#46;7&#41;&#46; The mean cost reduction per patient was &#36;713&#46; Similar findings were found by Weber et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">46</span></a> while Levine et al&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">47</span></a> reported no differences in costs&#46; Kono et al&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">48</span></a> even reported an increase in costs&#46; An RCS in the San Francisco area<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">49</span></a> assessed the impact of the Seniors Care Connection program on 280 patients with multimorbidity in the intervention group&#46; The intervention was conducted by a primary care-focused team&#44; consisting of a physician&#44; a nurse and a social worker&#44; with specific training in chronic diseases&#44; and telephone calls and home visits at least once every 6 weeks for 2 years&#46; The study showed a reduction in the number of admissions per patient per year &#40;0&#46;36 vs&#46; 0&#46;52&#41; and in the frequency of readmissions at 2 months &#40;3&#46;6&#37; vs&#46; 9&#46;4&#37;&#41;&#44; which resulted in a cost reduction of &#36;90 per patient&#46; Another high-quality RCS<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">47</span></a> was subsequently published and included an intervention group of 156 patients with multimorbidity from 3 counties in Los Angeles&#46; The study assessed the effect of the Choices for Healthy Aging care program &#40;which included 5 areas of performance of the CCM&#41; by conducting a 12-month follow-up&#46; In the intervention group&#44; the likelihood of hospital admission was lowered &#40;25&#46;6&#37; vs&#46; 37&#46;1&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#46; The study also found increased satisfaction with the care&#44; with no differences in terms of costs&#46; Of the previously mentioned high-quality studies&#44; nine found no notable benefits in the use of healthcare services&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">46&#44;48&#44;50&#8211;56</span></a> In terms of functionality&#44; three studies<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">57&#8211;59</span></a> found an improvement in daily life activities&#44; while four others found no differences&#46;<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">48&#44;50&#44;51&#44;60</span></a> Recently&#44; in our healthcare community&#44; Lanzeta et al&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">61</span></a> conducted an RCS on an intervention group of 70 polypathological patients from the Goierri-Alto Urola healthcare district&#44; who were hospitalized at least once the previous year&#46; The intervention included activities in four areas of the CCM&#44; and the patients were treated by a physician and a primary care nurse&#44; with the support of a reference internist and a nurse liaison&#44; conducting a comprehensive assessment and health education&#46; The intervention scheduled in the study was no more efficient than the standard healthcare&#46; However&#44; the statistical analysis revealed that in the patient subgroup younger than 80 years and with at least three clinical categories defining polypathological patients&#44; the intervention achieved cost reductions in 89&#37; of the simulations&#44; although the differences were not significant&#46; The simulation consisted of a statistical exercise that helped estimate the effect of an intervention on an imaginary population that mimicked the actual population group for which the intervention was to be performed on&#46; The authors interpreted these results assuming that the changes previously introduced in the healthcare organization and in the clinical management could have changed the polypathological patients&#8217; natural history&#44; improving their prognosis&#46; This could justify the absence of significant positive results in the study interventions&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">61</span></a> The data support the need to identify patient subgroups who can benefit from the interventions&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Considering the current difficulty in decision making&#44; it would be useful to improve 3 aspects of the healthcare programs directed at polypathological patients&#46; Firstly&#44; the chosen design should provide evidence in those conditions in which an experimental approach is not possible&#46; Choosing the so-called &#8220;natural experiment&#8221; could help&#44;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">62</span></a> which includes all individuals with a clinical condition that is the object of intervention &#40;in this case&#44; polypathological patients&#41;&#44; although this is not completely applied to all patients who meet the condition being studied&#46; Secondly&#44; the coordination of the interventions on polypathological patients should be improved&#46; We need to develop&#44; in the European setting&#44; an observatory that acts as a platform for exchanging knowledge and that helps identify&#44; validate&#44; exchange and spread the good practices on chronic diseases from member states of the European Union&#46; Along this line&#44; experience is being gained from JA-CHRODIS&#44;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">63</span></a> which is expected to meet this objective&#46; Finally&#44; in the development and assessment of the programs&#44; we need to promote the common elements that improve external validity&#44; adapting them to the specific characteristics of each country&#39;s healthcare policy&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In short&#44; the prevalence of chronic diseases has changed the way in which the population gets ill&#46; The proposed healthcare models have implemented activities aimed at addressing the needs of these patients&#44; probably achieving improved patient satisfaction&#44; quality of life and functional condition&#46; Healthcare organizations should continue to smoothly transform themselves to answer this new healthcare challenge&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">64</span></a> We also need to define which sector of patients and in what type of interventions the most relevant benefits are produced&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "General characteristics of the healthcare models for chronic diseases"
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          "titulo" => "Care models for polypathological patients"
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              "titulo" => "Other chronicity care plans in countries of the European Union"
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                  "titulo" => "SIPA Model &#40;&#201;valuation du Syst&#232;me Int&#233;gr&#233; pour Personnes &#194;g&#233;es fr&#225;giles&#41;"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Polypathological patients have specific clinical&#44; functional&#44; psychoaffective&#44; social&#44; family and spiritual characteristics&#46; These patients are generally elderly and frail and have frequent decompensations&#46; They frequently use healthcare resources&#44; have significant functional impairment and have a high index of dependence&#46; This results in a significant social impact&#44; high mortality and a high consumption of resources&#46; The current healthcare models have not answered these needs&#44; which causes problems with accessibility to healthcare services&#44; a lack of coordination among these services&#44; a higher probability of adverse events related to polypharmacy and a high consumption of resources&#46; In the past decade&#44; the healthcare models have changed and are characterized by work in multidisciplinary and interlevel teams&#44; patient self-care&#44; the availability of tools for decision making&#44; information and communication systems and prevention&#46; The goal is to have prepared and proactive health teams and an informed and active patient population&#46; The assessment of health results&#44; processes and the costs for these programs is still based on moderate to low evidence&#46; It is therefore not an easy task to determine the type and intensity of interventions or to determine the patient groups that could gain more benefits&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los pacientes pluripatol&#243;gicos tienen unas caracter&#237;sticas cl&#237;nicas&#44; funcionales&#44; psicoafectivas&#44; sociofamiliares y espirituales espec&#237;ficas&#46; Son generalmente de edad avanzada&#44; fr&#225;giles&#44; con frecuentes descompensaciones&#44; uso frecuente de recursos sanitarios&#44; deterioro funcional importante y un elevado &#237;ndice de dependencia&#59; de lo que se deriva un importante impacto social&#44; mortalidad elevada y consumo de recursos&#46; Los modelos asistenciales actuales no han dado respuesta a estas necesidades&#44; lo que produce problemas en la accesibilidad a los servicios sanitarios&#44; descoordinaci&#243;n entre estos&#44; mayor probabilidad de eventos adversos relacionados con la polimedicaci&#243;n y un alto consumo de recursos&#46; En la &#250;ltima d&#233;cada&#44; los modelos asistenciales est&#225;n cambiando y se caracterizan por el trabajo en equipo multidisciplinar e interniveles&#44; el autocuidado del paciente&#44; la disponibilidad de herramientas para la toma de decisiones&#44; los sistemas de informaci&#243;n y comunicaci&#243;n y la prevenci&#243;n&#46; Se pretende conseguir un equipo de salud preparado y proactivo y una poblaci&#243;n de pacientes informados y activados&#46; La evaluaci&#243;n de los resultados en salud&#44; procesos y costes de estos programas&#44; se apoya todav&#237;a en evidencias moderadas o bajas&#46; Por ello&#44; no es f&#225;cil determinar el tipo e intensidad de las intervenciones&#44; ni los grupos de pacientes sobre los que pueden aportar m&#225;s beneficios&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fern&#225;ndez Moyano A&#44; Mach&#237;n L&#225;zaro JM&#44; Mart&#237;n Escalante MD&#44; Aller Hernandez MB&#44; Vallejo Maroto I&#46; Modelos de atenci&#243;n al paciente pluripatol&#243;gico&#46; Rev Clin Esp&#46; 2017&#59;217&#58;351&#8211;358&#46;</p>"
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        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; Innovative care for chronic conditions&#58; organization and delivery of high-quality care of noncommunicable chronic diseases in the Americas&#46;"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The care model for patients with chronic diseases&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Source&#58; adapted from Garc&#237;a-Gonz&#225;lvez&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">42</span></a></p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year of legal deposit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Health Promotion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Disease prevention and limitations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Continuity of care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Healthcare reorientation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Research and innovation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aragon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Basque Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Andalusia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Castilla-Le&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Murcia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Navarra&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Madrid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C&#46; of Valencia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asturias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">La Rioja&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Galicia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Canary Islands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cantabria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Castilla-La Mancha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Catalonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Relationship between the lines proposed by the Spanish National System of Health and its inclusion in the guidelines of the autonomous communities&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Advanced nursing competencies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; School of patients or active or expert patient-caregiver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Unified electronic medical history&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Electronic prescription&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Multichannel health department centers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Hospital units for subacute patients or medium stay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Home hospitalization units&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Health portal or personal health folder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Hospital units for acute patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Specific programs or units for polypathological patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Relationship of the most common activities &#40;resources&#44; practitioner profiles and activities&#41; of the various care models&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
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          "identificador" => "bibs0005"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2017.05.001

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