Sufferers from chronic conditions tend to slip under the radar of the health system. this is because for decades the system has been based upon the logic of rescue, of saving lives and so, therefore, has focused on acute illnesses. faced with the increase in chronic illnesses it is necessary to complement this system with one which deals in terms of caring as well as curing, one which offers continuity of care throughout a person’s life, with the added potential of preventing unnecessary hospitalizations and thus reducing costs.

1. A Strategy
to Tackle the
Challenge
of Chronicity
in the Basque
Country
July 2010

2. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
Foreword
Sufferers from chronic conditions tend to slip under the radar of the health system. this is
because for decades the system has been based upon the logic of rescue, of saving lives and
so, therefore, has focused on acute illnesses. faced with the increase in chronic illnesses it
is necessary to complement this system with one which deals in terms of caring as well as
curing, one which offers continuity of care throughout a person’s life, with the added potential
of preventing unnecessary hospitalizations and thus reducing costs.
in the forthcoming two decades 26% of all Basques, the baby boomers, will belong to the
over 65 age group. for the first time our society must prepare itself for a situation in which
those who, today, are aged 50 will have to care for their parents for longer than they have
looked after their children. Without major changes in our social policies and in the concept
we have of ageing, it will be impossible to face up to the challenges of the current social
panorama.
this document proposes what is to be done and the steps to be taken in order to achieve just
that in the Basque country.
Medicine and bioscience will bring new discoveries in the decades to come. Many of these
will save lives and will be fundamental for chronic patients. however, there are two other
significant areas which will change: healthcare to the same degree as biomedical progress
and which will also save a great number of lives and which will also be essential for chronic
patients. i refer to the advance in information technologies and the organization of services.
the Strategy described in this text values these advances equally to those of the progresses
in biomedicine, pointing out that bioscience alone is not enough to face the challenge of
chronicity in our societies.
the way the health care system is organized at the provider level will become more and more
important as we move forward. it should become as important as the treatments it provides.
furthermore, in managerial terms, it will not be possible to improve the system by focusing
only on the internal performance of care organizations. the improvement in coordination
between them is even more important. Primary care, hospitals and social services are
interdependent. it is necessary for them to find more collaborative and better coordinated
approaches. it is in this collaboration in which advances are to be found for chronic patients
and in which wide margins for efficiency improvements can be identified which will enable
the sustainability of the health system. to this end, it will be necessary to cease to manage
structures and to learn to manage integrated health systems, especially on a local level.
in the Basque country we have a public nhS type of health care system. All health care
professionals are salaried in both primary health care and hospital care. the important lesson
of the past years is that despite this apparently tidy vertically integrated system in management
terms, at the provider level this system has not achieved integrated clinical care and continuity
of care. Management integration at all levels does not guarantee clinical integration where we
need it at the provider level. it is therefore necessary to do something different. this Strategy
provides the context to do something different.

3. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
the basic premise therefore is to avoid taking any policy decisions which might further fragment
care and, rather, ensure we are developing local systems of care which offer continuity of
care. consequently, the policy context in the Basque country will strive to build collaboration
rather than competition and more concretely, what we propose is not a magic wand, but an
organized progression, activating many levers of change.
investment is required in an information strategy and the technology to make it possible, it is
necessary to use new approaches to educate patients to manage their illness, to continue to
promote evidenced-based medicine, and also to integrate primary care, hospital care and
social care and to develop new professions which integrate care.
iit is necessary to manage all these levers simultaneously. coordinated activation of all these
levers will provide the required set of tools with which to bring about the necessary change.
they are presented here as strategic interventions which will enable us to meet the most
complex and important challenge of recent decades: that of organizing a health system worthy
of the chronically ill, the most significant challenge of the 21st century.
Although not in all cases, many of these new interventions will bring new efficiencies. they
should all however and without exception provide better care and security for chronic patients.
furthermore, many of our management and leadership concepts must change. none of this
will be achieved with the kind of leadership we have known in the past. the complexity of the
change requires the development of a different leadership approach in the forthcoming decade.
With the aim of reaching the necessary alignment between local and corporate level, we are
committed to a better distribution of leadership, in which central management create the
conditions to promote organization innovations which are inspired by local management and
health professionals themselves. it is in this local arena in which the main innovations necessary
for chronic patients will be found.
rafael Bengoa
Minister of Health and Consumer Affairs
Basque Government
1

4. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
2

5. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
Content
Introduction 4
The challenge and the opportunity presented by chronicity in the Basque Country 6
2.1 chronicity in the Basque country 7
2.2 the different needs of the chronically ill patient 13
2.3 reference and care intervention models for the chronically ill 14
2.4 What does the evidence say? 18
The need for a system strategy 22
The strategy for the Basque Country 26
4.1 Vision of the future 27
4.2 Policies 30
4.3 Strategic Projects 37
Achieving change: Introduction strategy 60
Accepting complexity 61
top-Down and Bottom-up 62
Index of tables and figures 66
tables 66
figures 67
Barring indications otherwise, this study is published under Creative Commons licence (BY)
For further information and complete license: http://creativecommons.org/licenses/by/3.0/deed.en
Photographs: ©M. Arrazola - EJ-GV (Unless otherwise indicated at the foot of the photo)
Edited by Eusko Jaurlaritza – Basque Government – Department of Health and Consumer Affairs.
Dep. Legal - BI-2345-2010
3

6. Introduction

7. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
We often confuse interim short-term tactics with medium term strategies. the former can
be found in abundance, the latter are in short supply.
this document provides a framework of action for the medium term transformation of
the Basque health System. it is independent but complementary to the interim measures
and management policies that have been put in place due to the current economic crisis.
While the interim measures attempt to reduce expenditure in the short term in order to
ensure sustainability, the final result of this Chronic Patients Strategy aims to outline
a new way of organizing care causing an impact on each and every aspect of the system
(health results, satisfaction, patient and carer life quality, and sustainability). thus, this
structural transformation goes beyond the current economic situation, requiring a long
period (at least between 2 and 5 years) before achieving a substantial impact on the
system.
life expectancy for the Basque population has extended considerably in recent decades
and a significant parallel change has taken place in life styles. one consequence of this
is that the prevalence of people suffering from chronic illnesses is increasing to the extent
that the great majority of patients in our health system are suffering from one or more
chronic illnesses.
The response to the needs of people suffering from chronic illnesses has become the
principal challenge faced by the Basque Health System (BHS). these pathologies have
a multiple impact: they represent a considerable restraint on life-quality, productivity and
the functional state of people who suffer from them; they exert a strong influence on
morbidity and mortality rates; and they accelerate the increase in health and social costs,
which compromises the medium term sustainability of the healthcare system.
the path towards progress in this area requires a change in the existing conceptual
frameworks, within which curing and caring, take place, and one which is clearly outlined
in the current health and social policies. The individuals and their environment, their
health and their needs have become the central focus of the System at the expense
of merely treating the illness.
the existence of a higher number of chronic conditions in a person generally leads to a
greater risk of incapacity and mortality, and within the chronic pathologies there are some
which are notoriously disabling. this close relationship between chronic illnesses and
dependence is the determining factor with regard to prioritizing and indentifying the most
suitable health and social policies.
in addition, chronicity implies a challenge to the quality of care provided, as the people
who suffer from chronic illnesses are more likely to receive less than optimum care and
to suffer adverse pharmacological side-effects.
furthermore, the challenge of chronicity requires proactive measures to combat the health
factors which give rise to it in the first place. hence the importance of anticipation, setting
up a framework of action which reduces its emergence and progression by means of
awareness and preventive actions.
to summarize, chronicity is a in system terms global challenge and consequently requires
a systematic response. Beyond particular illnesses or specific groups of sufferers, it is a
challenge which must take into account everything from the structural conditions and
the lifestyles which contribute to the increase of the pathologies in question to the social
and health requirements of the chronically ill patients and their carers: from the initial
stages up until the care provided during the final phase of life, including all aspects of
care, convalescence, and rehabilitation.
This Strategy aims to improve the health and welfare of all people who are affected
by chronic illnesses, as well as to reduce both the level and the impact of chronicity.
5

8. The challenge
and the
opportunity
presented by
Chronicity in
the Basque
Country

9. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
2 .1 T h e c h a l l e n g e a n d T h e o p p o r T u n i T y
presenTed by chroniciT y in The
basque counTry
the prevalence of chronic illnesses increases according to age groups in all cases, but
considerably so for those aged over 65, diabetes and osteoarticular pathologies reflecting
the highest increases.
in the majority of pathologies, an increase can also be observed in the prevalence among
the over 85 age group, especially in the case of neurodegenerative dementias.
comparing the most recent data (eScAV’07) with the prevalence data for chronic problems
included in the Basque country health Surveys from 1997 and 2002, it can be seen
that the percentage of chronic patients increases in the over 45 age group, which is of
particular concern in the current context of population ageing, and, logically, an increase
in the more advanced age groups is to be expected in the near future.
According to the Basque health Survey carried out in 2007 (eScAV’07) 41.5% of men
46.3% of women stated they were suffering from at least one chronic health problem.
As can be seen in figure 1, the prevalence of chronic problems was higher in women
than in men (with the exception of the under 17 age group) and this difference increased
with age.
Figure 1
Prevalence of chronic problems according to age and sex
100
90
80
70
60
% 50
40
30
20 Men
10
Women
0
<17 18-44 45-64 >65
Age
fuente: elaboración a partir de eScAV 2007
Similarly, among the elderly (over 65 years of age) it is not uncommon to find persons
with multiple chronic pathologies. Patients with this profile run the risk of suffering some
kind of disability or death.
7

10. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
Figure 2
Distribution of the population aged over 65 according to the number of chronic problems
8,6 %
23,4 % None
One
28,9 %
Two
Three or more
39,1 %
Source: Data from eScAV 2007
in fact, the clinical data provide a clear vision of the number of chronic conditions according
to patient age, as can be seen in figure 3.
Figure 3
Distribution of patients according to the number of chronic illness by age
80%
70%
60%
50%
6+ illnesses
% 40%
5 illnesses
30% 4 illnesses
20% 3 illnesses
10% 2 illnesses
0% 1 illnesses
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95+
Age
Source osabide 2007
8

11. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
this multimorbidity reflects conditions which are particularly representative, not least
when it constitutes a wide spectrum of chronic illnesses combined in different ways.
Figure 4
Main medical conditions appearing in patients with multimorbidity
(3+ chronic illnesses) according to the primary care diagnosis
70%
65%
60%
50%
39%
40% 35%
30%
23%
18%
20%
13%
10% 9% 9%
10% 5% 4%
0%
n
ia
es
s
n
ia
C
n
a
I
re
CC
iti
m
sio
i
io
O
m
em
pa
ilu
t
hr
be
h
ss
EP
pe
en
st
fa
h
al
rt
re
ia
isc
A
li
t
A
ic
ey
ep
er
D
er
rv
ac
dn
yp
yp
D
Ce
i
H
ki
H
rd
Ca
ic
n
ro
Ch
Source osabide 2007
from the comparison of the most recent data concerning the prevalence of chronic
conditions (eScAV’07) with the data from the health Surveys in 1997 and 2002, it can
be observed that the percentage of chronic patients is increasing, above all in the more
advanced age groups (figure 5). for example in the case of persons aged between 45
and 64 in 2007, compared to the figure for 1997, there were almost 90,000 more people
who declared some kind of chronic ailment.
Figure 5
Change in the percentage of persons with chronic problems between 1997 and
2007 according to their age
90
80
70
60
50
%
40
1997
30
20 2000
10
2007
0
<17 18-44 45-64 >65
Age
Source: eScAV
9

12. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
in fact, a retrospective analysis of certain illnesses reveals that their prevalence is increasing
at a considerable pace.
Figure 6: Change in the prevalence of diabetes and cardiovascular disease
in the Basque Country
In 15 years the prevalence of chronicity in the Basque Country has increased
notably throughout the region
Percentage
1992 1997 2002 2007
4,5 - 6,0 6,1 - 7,5 7,5 - 9,0 9,1 - 10,5 10,6 - 12,0
Source: eScAV 1992, 1997, 2002, 2007
in order to provide a more detailed picture of chronicity in the Basque population a series
of illnesses was selected according to the following criteria:
• the principal diagnosed chronic illnesses (neoplasias were not included due to their
special characteristics)
• the main causes of mortality.
the following figure outlines the number of chronic patients aged over 18 with each of
these conditions, along with their prevalence according to the diagnoses in Primary care.
it can be observed that the osteoarticular pathologies along with diabetes are the most
common illnesses among the Basque population.
Figure 7
Number (and prevalence) of chronic patients over the age of 18 suffering from
the principal pathologies (according to diagnoses in Primary Care)
Arterial Hypertension 172.820 (10,33%)
Hypercholesterolemia 117.280 (7,01%)
Osteoarticular Pathology 74.402 (4,45%)
Diabetes 71.656 (4,28%)
Asthma 34.154 (2,04%)
Cardiovascular Diseases 33.246 (1,99%)
Neurodegenerative Dementias 23.153 (1,38%)
COPD 22.995 (1,37%)
Obesity 18.469 (1,10%)
Source: own data from osabide
10

13. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
A more detailed analysis on the age distribution of these chronic pathologies indicates
that the degree of prevalence is increasing, in almost all cases, considerably so from the
age of 65, with the increase being especially notable in the osteoarticular pathologies
(>13%) and diabetes, which reaches a prevalence level of above 12%. neurodegenerative
dementias become particularly apparent from the age of 85 onwards.
Figure 8
Prevalence of the principal pathologies by age groups (according to diagnoses in
Primary Care)
25,00
20,00
Prevalence (%)
25,00
10,00 18 a 44
5,00 45 a 64
65 or above
0,00
C
s
a
r
s
ar
la
tia
te
hm
O
ul
cu
be
EP
en
tic
st
as
ia
em
A
ar
ov
D
eo
D
i
rd
st
Ca
O
Source: own data from osabide
11

14. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
the study carried out by the Department of health in 2008 “the impact of different
illnesses on the health of the Autonomous community of the Basque country” reveals
that, among the selected illnesses, those with the greatest influence on mortality rates
for men were the cardiovascular and ePoc diseases, which caused 16.4% and 6%
respectively of all deaths. in the case of women, cardiovascular illnesses were also the
major cause of deaths (17.3%), while diabetes was the second most dangerous (3%).
on the other hand, in spite of not having such a high impact on mortality rates,
osteoarticular pathologies are very relevant in as far as disability is concerned. the study
estimated that out of all males suffering from a disability, 26.6% could be attributed to
this kind of pathology. As for women, the influence of these illnesses on disabilities was
even higher, with a prevalence of osteoarticular pathologies among disabled women of
45%.
this situation of prevalence and increasing incidence of chronic pathologies is not a
phenomena limited only to the Basque country, but one which is also taking place
throughout Spain, with an expected annual increase, according to the prevalence data
from the Patient Base of Decision resources, of approximately 1.2% in the number of
type 2 diabetics among the Spanish population aged over 20, rising to affect some 7.7%
of the population by the year 2016. this increase in prevalence also occurs, to a greater
or lesser extent, in a great number of regions throughout the world, being, furthermore
a tendency, which according to forecasts, will continue to increase, aggravating even
further an epidemiological situation which is already very serious.
Figure 9: Illustration of the forecast for chronic illnesses throughout the
world – Example Diabetes
A nivel mundial las enfermedades crónicas tienen las características de una
pandemia en expansión.
On a global level chronic illnesses bear the characteristics
of a pandemic in expansion <4 4 to <8 8 to 14 >14
Forecast of the change in levels of diabetes on a global level(1)
2007 2025
Source International Diabetes Federation
Source: international Diabetes federation: Diabetes Atlas
12

15. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
2 . 2 d i F F e r e n T i a l n e e d s o F T h e c h r o n i c a l ly
i l l paT i e n T
Although chronic illness is defined by a standard list of defined pathologies, it does present
a series of differential factors: long duration, slow and continuous progression, it decreases
the quality of life of those affected, and frequently reflects a significant level of comorbidity.
furthermore, it is a cause of premature death and has significant economic repercussions
for families and society in general.
for the purposes of analysis and the approach followed in this document the following
list and characteristics have been used.
Table 1: list (not exhaustive) of chronic illnesses and their characteristics
Chronic illnesses are very widespread and have certain characteristics in common
Possible illnesses considered
chronic Common characteristics
1 They have multiple causes and complications
Diabetes mellitus 2 They normally appear gradually, although they can appear
Cardiovascular diseases suddenly and present acute states
(Ischemic cardiomyopathy,
cardiac insufficiency, cerebral 3 They emerge throughout the life cycle though they are more
vascular illness) prevalent in the elderly
Chronic respiratory diseases 4 They compromise the quality of life causing functional limitations
(EPOC, asthma) and disability
Osteoarticular diseases 5 They are long lasting and persistent and result in a gradual
(rheumatoid arthritis and severe deterioration in health
arthrosis) 6 They require long term medical care and attention
Neurological diseases (epilepsy, 7 In spite of not being immediately life threatening they are the
Parkinson’s disease, multiple most common cause of premature death
sclerosis)
8 In some cases they are limited to non-contagious diseases,
Mental illnesses (dementia, although more recently they have been included illnesses such as
psychosis, depression)) AIDS or tuberculosis
HIV/AIDS 9 Fortunately, a significant number of them can be prevented or
Digestive diseases (chronic their appearance can be delayed, while in others, given the level
cirrhosis and hepatopathy, of current communication, their progress can be slowed down
ulcerative colitis, Crohn’s and their associated complications reduced
disease) 10 The distribution of the conditions and causes that favour the
Chronic renal diseases … development of these illnesses in a population is not uniform,
being the less well-off sectors which present greater frequency.
The growing accumulation of risk factors in these less well-off
groups will continue to increase the gap in health results
Source: health Study and research Services of the Department of health and consumer Affairs of the Basque government
Beyond the specific chronic illness or combination of illnesses, the focus of these
differences is the phenomena of chronicity and the factors involved since its outset, the
treatment, be it preventive, curative, palliative, or rehabilitation, up until the final stages,
with the chronic patient in the centre of the care pathway. this evolving social construct
which we call chronicity encompasses patients with different diseases and at different
levels of seriousness. With this in mind, the focus of this document is global and is not
devoted solely to specific diseases.
13

16. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
Whatever the particular illness, the most important factors in the interventions in chronic
procedures are different to those for acute illnesses.
1. they require a complete diagnosis of the patient including their social situation and
their role as opposed to a traditional diagnosis focussed on the illness and the acute
symptoms.
2. Proactive, preventive (primary and secondary) and rehabilitation interventions are
more important than a typically curative focus on the acute illness.
3. the patient and the carer play a much more important role in the successful outcome
of the intervention with the need to change life styles and adhere to these over long
periods in contrast to the traditionally passive role of the care receiver.
4. they require a coordinated approach to care with an “individual vision” at all levels
of care (primary, specialized, medium stay, mental health, emergencies, social services,
health at work, etc.) throughout the duration of the illness as opposed to a rapid and
specialized action on the part of a limited number of specific departments.
5. the needs and priorities (medical but also emotional, social, material and even
spiritual) of each patient are given more importance considering that we are often
dealing with continual interventions over the remaining lifetime of an individual
compared to a specific intervention which has a limited impact on a person’s quality
of life in the mid-term.
these differences in the focus of the interventions are such that the phenomena of
chronicity requires a model of care different to that typically used for acute illnesses.
2.3 Fr aMeWorKs and care inTerVenTion
M o d e l s F o r T h e c h r o n i c a l ly i l l
currently there exists, at a global level, a broad base of highly developed theoretical
models. in addition, in recent years, specific interventions have been outlined, the efficacy
of which can be tested as they have been carried out in various health systems in different
parts of the world. Specifically, in this section the main reference models have been
included (ccM, iccc, kaiser Pyramid of care, the king’s fund Pyramid) along with some
examples of interventions with scientific evidence.
Probably, the outstanding international reference model for chronic patient care is the
Chronic Care Model CCM developed by ed Wagner and by collaborators from the Maccoll
institute for healthcare innovation in Seattle, in the uSA.
in this model, care for chronic patients takes place on three overlapping levels: 1) the
community with its policies and multiple public and privates resources; 2) the health
system with its supplier organizations and insurance schemes; and 3) the interaction
with the patient in the clinical practice.
14

17. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
Table 2
Adaptation of the care model for Chronic Patients in the Basque Country
Health system
Organization of health system
Self- Design of Medical Decision
Community, management provision information support
Resources and system systems
Policies
Activated Proactive
Informed Productive Health
Patient Interactions Team
Medical and functional
results
Source- Developed by ed Wagner and collaborators from the Maccoll institute for healthcare innovation. Adapted by o+berri
Basque institute of health innovation
this framework identifies six essential elements which interact among themselves and
which are key to achieving optimum care for chronic patients. these are:
• organization of the healthcare system.
• Strengthening of links with the community.
• fostering and support for self-care.
• Design of the care system.
• Decision making support.
• Developing clinical information systems.
the final objective of the model is that active informed patients become the protagonists
of the medical encounter along with a team of proactive professionals with the requisite
capabilities and skills, all in pursuit of a high quality level of care, increased satisfaction
and improved results.
Standing out among the adaptations of the ccM is the model proposed by the World
health organisation, known as “The Innovative Care for Chronic Conditions Framework
(ICCC)”.
15

18. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
Table 3
The Model of Innovative Care and Chronic Conditions (ICCC)
Framework of Positive Policies
Strengthening of alliances • Development and assignation of human resources • Policy integration
• Support from the legislative framework • Guarantee of suitable financing • Leadership and
support
Health Organization
Community Fostering continuity and
coordination.
Awareness and taking
Prepared
away stigma. Promoting quality
through leadership and
Promoting better results incentives.
through leadership and
en ity
He team
support. Organization and
Ag mun
alt s
ts
funding of the health
hC
Mobilization and coordi- care teams.
m
nation of resources.
are
Co Use of information
Provision of complemen-
d Mo systems.
me tiv
tary services.
o Patient and ated
r Support for self-care and
Inf prevention.
family
Better results for chronic conditions
Source: Who
this model adds to the ccM a model health policy perspective of which the main ideas
are the following:
• Decision-taking based on evidence
• focus on the health of the population
• focus on prevention
• emphasis on the quality of care and on system quality
• flexibility/adaptability
• integration, as the hard fractal core of the model
Apart from the system models such as ccM and the iccc, the other type most frequently
used is that which refers to population models, the focus of which is the population as a
whole and its needs instead of those of the health care system. Standing out among these
is the “Kaiser Pyramid” which identifies three levels of intervention depending on the
level of complexity of the chronic patient. in posterior interpretations to the kaiser model
the population aspect of promotion and prevention has been included. the main idea
set out by the kaiser Pyramid is one of segmentation or stratification of the population
according to its needs:
in the patients with more complicated cases with frequent comorbidity an integral
management of the case is required with the provision of fundamentally professional care.
• high risk patients but whose cases are less complex as far as comorbidity is concerned
receive a disease management approach which combines self-management and
professional care.
• the majority of chronic patients with conditions which are still incipient receive support
for the self-management of their illness.
• finally, the general population is the focus of promotion and prevention actions which
aim to control the risk factors which might contribute to the development of chronic
illnesses in individuals.
16

19. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
Table 4
Extended Kaiser Pyramid
Professional
care
Patients with
severe complications (5%)
Case
Self-care Management
Illness High risk patients (15%)
Management
Chronic
Self-management support patients (70-80%)
Promotion and Prevention General Population
Source: kaiser Permanent. Adapted
one of the most interesting adaptations of the kaiser Pyramid which has been put into
practice is the pyramid defined by the king’s fund in the united kingdom. in this adaptation
what stands out is the combination of the health and the social vision as two integral
parts of the care requires by a person.
17

20. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
Table 5
Pyramid defined by King’s Fund in the United Kingdom
Pyramid de ned by King’s Fund in the United Kingdom
Adapt the service to the individual
Social vision Health vision
Support people Individuals with highly
who have more needs at home; complex needs/morbidity;
take them away from permanent residences Level 3 improve the care for chronic patients;
Case separate them from acute care
Management
High quality support Higher risk patients;
to carers at home Level 2 specific interventions
Managing to combat the illness;
early diagnosis
the illness
Appreciate people’s value; 70%-80% of individuals;
investment in voluntary Level 1 health promotion;
prevention services nutrition; exercise
Self- Management
Source: king’s fund (c.ham)
2 . 4 W h aT d o e s T h e e V i d e n c e s ay ?
As well as conceptual frameworks of action, there have also been interventions in recent
years which have offered scientific evidence of their effectiveness, revealing the possibility
of improving results at different levels (health results, patient and carer satisfaction and
quality of life, sustainability) by changing the way of managing chronic illnesses. nevertheless,
the majority of these interventions have been carried out in particular health systems and
their extension and adoption by other systems has been limited and difficult. this only
underlines the complexity associated with the implementation of these interventions and
the change in systems to the level required by the model.
Among these interventions a significant number have shown improvements in patient and
carer satisfaction levels (e.g. care coordination, case management, telemedicine).
in relation to the results corresponding to health outcomes and efficiency improvements
there are fewer specific examples with clear evidence (e.g. case management by nursing
– Boyd/Boult). however, the systems which have given clear backing to these kinds of
models (e.g. kaiser Permanente in the uSA, Jonkopping, in Sweden, various area health
authorities in england, canada, new Zealand and Scotland) in general demonstrate better
health outcome results than comparable institutions with a high level of efficiency.
for the design of this Strategy for tackling the challenge of chronicity in the Basque country
we have taken into consideration:
• the reference of the models outlined above, as well as the interventions which have
proven to be effective.
• the collaboration of the international centres of excellence mentioned above, many
of which were represented at the international congress organized in Bilbao (2nd-3rd
June 2010) with the objective of contrasting and comparing their experiences with
the strategic proposal designed for our situation.
18

21. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
• the thorough national and international analyses of all the evidence relating to the
management of chronic illnesses.
We include below in the section “ the relationship with health Systems Sustainibility “ a
summary of the most significant conclusions of these analyses1.
it is important to highlight that the evidence in favour of the interventions indicated in this
Strategy is growing, indicating that there are numerous opportunities for the Basque health
System.
indications are that investments in this line of action in general will be beneficial for patients,
will be cost-effective, will reduce the number of hospital admissions, that they will improve
efficiency and will reduce the mortality rate.
The relationship with Health System sustainability
the basic notion resulting from these studies with regard to efficiency can be resumed as
follows:
• it is necessary to organize a system which is able to deal with comorbidity and not
merely to deal with one illness at a time, (35% of people aged over 80 suffer from two
or more chronic illnesses).
• the most significant potential benefits arise from the prevention of the unnecessary
admission of complex patients into the hospital system.
• the cases which activate a sole intervention (e.g. remote medical monitoring from
home, or training patients for self-management) may not achieve the desired efficiency
impact. to obtain efficiency improvements, it is necessary to systematically intervene,
working several levers of change, using the models outlined above in an integrated
and coordinated fashion.
• economic results will appear in the mid term.
• it is worth “noting down” the management interventions of chronic patients according
to the predictions of high use (e.g. recent hospitalization, frequent use of emergency
wards, certain medical indicators). By acting in this way, saving opportunities will be
substantially enhanced.
• individualized planning previous to admission and advice from multi-disciplinary teams
guarantees substantial reductions in avoidable re-admissions, even in the absence of
other interventions.
• When patient groups are easily identifiable and classifiable, face-to-face interventions
which combine education with clinical care including contact with primary care or
hospital specialists, as well as remote electronic monitoring are considered worthwhile
in efficiency terms. consequent reduction in use and expenditure tends to be positive.
• intensive and individualized education combined with treatment is more effective with
diabetic patients (with the exception of the elderly) and with asthmatic patients.
• interventions based on opportunistic education during the patient-doctor interaction
tends to be less effective compared to highly intensive educational interventions
focussed on patient self-management.
• interventions for the management of congestive cardiac failure and for the elderly with
multiple conditions have proved to be the most fertile area for achieving health
improvements and relevant economic savings.
• Studies confirm an positive return on investment in congestive cardiac diseases,
asthma, and with patients with multi-pathologies. the main saving would be in the
fall in admissions and readmissions as well as in daily costs.
1
Chronic Disease Management: Evidence of Predictable Savings; J. Meyer and B. Markham. 2008
19

22. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
• in asthmatic patients the saving is substantial due to the reduced use of the emergency
services.
• in chronically ill patients who were treated more intensively and individually, the fall in
hospital admissions was from 21% to as high as 48%; with asthma patients in particular,
the fall in admissions ranged between 11% and 60%. in diabetics hbA1c values
dropped by 1% and hospital admissions fell from between 9% and 43%. Among
elderly patients with multiple pathologies the fall in hospital admissions was from
between 9% and 44 %.
Although the evidence on the impact of the management of chronic care is heterogeneous
and generalizations should be carefully evaluated, the overall analysis indicates that significant
and foreseeable savings could be achieved.
this data confirms the growing interest in this line of work to ensure the SuStAinABility
of the Basque health System.
therefore the new Strategy for the Basque health Service has been designed along these
notions.
20

23. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
21

24. The need
for a
System
Strategy

25. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
As has been discussed in the previous section, in the Basque country, chronic illnesses
represent the dominant epidemiological situation of the country. it is estimated that they
currently represent 80% of the interactions with the Basque health System and account
for more than 77% of health expenditure. however, the basic characteristic of the current
care model is reactive, in which the patients have an episodic relationship with the health
system and this logic is not what chronic patients need. in fact the current System is designed
and structured to comply with an epidemiological model focussed mainly on acute
interventions which do not correspond to today’s needs. furthermore, there is a lack of
integration between the health system and the other social resources associated with health,
which, as has been seen, is of substantial importance for chronically ill patients.
Table 6: The reactive nature of the current system
The health system is still mainly reactive
Population has not We do not have We do not have
been stratified... case nurses... routine medical
reminders...
Care is fragmented... Patients are The patients who could
not activated... be are not telemonitored
Source: own elaboration
the structural tendency towards the increasing relevance of chronic patients means that
it is absolutely necessary to respond to their needs, both from the point of view of health
results and in order to guarantee the sustainability of the system in a situation in which
there is increasing pressure on expenditure.
Based on the above (epidemiological challenge, chronic patient needs, international
evidence….), this Strategy has been drawn up in order to adapt the Basque health System
to the current demands and those of the future in areas of prevention and care for chronic
illnesses. it is important to point out that this strategy is not a repudiation of the excellent
management of acute illnesses, but one which complements the current acute organisation
with the capacity to also respond adequately to the needs of chronic patients:
1. the challenge of chronicity goes beyond the illness and the symptoms, so the Strategy
needs to broaden its vision of the individual: not only their biomedical situation but
also their social and functional situation.
2. tackling chronicity also requires overcoming the conventional programmes of episodic
treatmen. it is necessary to try and reduce the appearance and the adverse effects
of chronic illness by means of a population approach in which prevention and health
promotion are key elements.
istockphoto - getty images
23

26. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
3. the patient and their carer cannot be passive elements in this strategy. they have a
central role which requires training and an increased awareness beyond that of their
traditionally passive role.
4. chronicity requires a holistic vision of the patient and an all-embracing and coordinated
focus both from within the health system (primary, specialized, medium-stay, mental
health, emergencies) and from beyond, embracing the institutions, Departments,
Programmes and available technologies and infrastructures directly related to chronicity
(social assistance, sport, health at work).
5. finally, chronicity requires that the range of available interventions is widened and
adjusted to the needs and priorities of the patients in each of the phases of their
illness (from the outset to the end of their lives, embracing convalescence and
rehabilitation).
this new strategic approach is supported by international trends and by the increasing
evidence of the effectiveness of the interventions and models mentioned in the previous
section, more in tune with the needs of chronic patients.
All in all, the Strategy is presented as an opportunity for change in the model to one in
which the agents involved participate in the establishment of a framework of action for
an integral management of chronicity from the population perspective, building upon the
existing capabilities of the system. the following table shows a series of emerging elements
which complement the existing model in the interests of achieving the aforementioned
change.
Table 7
Towards a new model for the Basque Health System
Current Elements Emerging Elements
Accessibility face–to-face remote
Product health services health value
Architecture Supplier focussed citizen focussed
of Service and of
Quality of the System
Management
• continuous and
• episodic
coordinated
Care Model • reactive
• Proactive
• hospital focussed
• integrated
• health
• Accessibility
Value Proposal • Prevention, cure, care
• focussed on care
and rehabilitation
Source: osaberri
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27. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
25

28. The strategy
for the
Basque
Country

29. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
the strategy designed for the transformation of the Basque health System along the lines
mentioned above is structured in the following way:
• it is based on a medium term Vision, which defines and describes the desired future
situation.
• it describes the health care Policies for chronic patients as guidelines for the successful
fulfilment of this vision.
• finally, there is a series of Strategic Projects which contribute towards generating and
implementing the change to make the policies and the vision a reality in each one of
its dimensions.
Table 8 Strategic Diagram
1 - Vision
2 - Policies
3 - Strategic
projects
4 .1 V i s i o n o F T h e F u T u r e
the Basque chronic Patients Strategy aims to respond to the needs generated by the
phenomena of chronicity in all the affected groups: chronic patients and their carers,
health workers, and citizens in general.
• for the chronic patients and their carers it will mean changing from a reactive system
to a proactive system which will offer them a more integrated level of care (coordination
between health levels and alignment with the social and employment agendas), more
continuity during the development of the illness (from prevention to the end of life,
including rehabilitation) and be more adapted to their needs. furthermore, they will
be given a role to fulfil and greater responsibility in the management of their own
health. All with the final objective of being able to offer patients better health results,
with greater levels of satisfaction as far as care and quality of life are concerned.
istockphoto - getty images
27

30. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
• for medical professionals it will represent the possibility of devoting more time to work
on issues of higher added value and having access to the necessary tools (e.g. more
complex diagnostics in primary care, tools to support changing patients behaviour).
furthermore the idea is to that the time invested in routine work will be automated
(e.g. prescriptions for long term treatment, coordination of the clinical history between
levels of care, basic health advice by telephone, case management by nursing) and
the tools will be given to the patients themselves or the carer.
• for citizens there will be a double benefit. As tax payers they will benefit from a more
efficient use of the systems resources, with the type and cost of each intervention
being adjusted to meet the attention and care needs of each case, thereby contributing
to the sustainability of the system. As potential chronic patients, they will participate
in the prevention of chronicity and the promotion of their own health, avoiding the
development of chronic conditions or at least reducing their impact on their health
and quality of life.
• for non-medical professionals and health service managers it will mean that their role
will be given more recognition, they will have confirmation of their impact on health
results and not only on the efficiency of the system, their co-leadership will be
broadened, they will witness the breaking of barriers which limited their area of action
and responsibility, as well enjoying the opportunity to share with other professionals
new areas of influence and collaboration.
Table 9: Vision of Strategy for Chronic Illnesses
The Strategy for Chronic Illnesses aspires to substantially improve the lives of patients and carers,
health professionals and citizens
Vision Better health results
Greater life
satisfaction and
Chronic Patients and quality
their Carers
Basque Health
More time for work system adapted to E cient use of
which has greater resources
added value
deal with Chronicity
Prevention of
Fewer routine chronicity and its
Health
jobs Citizens development
Professionals
28

31. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
this change will have an impact both on Primary care and on hospital care. it is not a
question of deciding where care should be provided, but accepting that care for chronic
patients nowadays is suboptimal mainly due to the lack of care continuity between our
levels of care. thus the logic of this Strategy is based on the premise that we are faced
with a problem of organization of clinical and preventive practices, both with regard to
primary care and hospital care.
care provided is still basically reactive to acute illnesses and episodes; that is, in a model
of acute illnesses the premise is to define the problem which is the subject of the clinical
consultation, to diagnose it and to initiate a treatment, usually pharmacological. the
consequence of this model of organization is that, when it is applied to a chronic patient,
that patient receives care which is more episodic than continuous, as this is how the system
has been conceived. Moreover, the consultation is normally determined by the acute
problems from which the patient is suffering. All this leads to a reactive model.
By contrast, we propose moving to a model of organization which is more proactive in order
to ensure:
• that patients have the confidence and the skills to manage their illness.
• that patients receive care that provides optimum monitoring of their illness and prevents
complications.
• that there is a continuous monitoring system both remote and face-to-face.
• that the patients have a self management plan, which has been mutually agreed with
health professionals, with which to control their illness.
• that we develop an organization with a preventive and continuous care logic, which
is designed between the patient and the clinical team.
experts agree that it is preferable to manage chronic illnesses in primary care, and the
models outlined in Section 2.3 of this document are based upon this logic. this strategy
continues this line of work, but it indicates that hospitals should also be innovative in their
management of chronic patients, as in many cases they have to be admitted to hospital.
thus hospitals play a fundamental role, as treating chronic patients during their acute
episodes is part of the integral management of those patients.
finally, what we are dealing with is a process of change which combines uniform elements
for all patients and agents of the system – an essential ingredient to guarantee the necessary
level of standardization in an ambitious strategic change – with the necessary adaptation
of various local situations arising from users and service organizations. for this reason, we
defend the need to better balance the dichotomy between the corporative and the local
perspective. that balance is achieved with certain global strategic frameworks, which
emanate from the centre and extend uniformly throughout the system and with the necessary
local freedom required for local application. this balance is further explained in the last
chapter of this strategy.
to realize this vision, it is necessary, not only to provide the system with the necessary
tools, but also to change substantially the “way of doing things”, with respect to the
organization of care; a change to be made both by the patients themselves and by the
social and health care professionals and managers. these changes are defined in the five
Policies of care for chronic patients explained in the following chapter.
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32. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
4.2 policies
the policies described below correspond to the principal areas requiring change in order
to be able to suitably address prevention, care, rehabilitation and health care for chronic
patients. As has been previously mentioned, these polices do not aim to replace the
current system of handling of acute illnesses, but in fact to complement it in order to be
able to offer excellent and efficient care to chronic patients. to put each one of these
policies into action, it will be necessary to strengthen the system in various areas, in order
to prepare a more adapted model geared to managing the phenomena of chronicity. this
section will focus on describing the aim and expected results of the policies, while details
of the concrete strategic projects can be found in the following section.
POLICY I. Adoption of a population health outlook, stratified and proactive population
Table 10: Policies
Health care for chronic patients will change with the introduction of five strategic policies
I Focus on strati ed
population health
Policies
II Promotion and Prevention
of chronic illnesses
III Responsibility and autonomy
for patients
IV Continuous care
for the chronic patient
V E cient interventions adapted
to the patient’s needs
Source: own elaboration
health management and reduction of inequalities in health matters.
Objective
the objective of the focus of population health is to improve the health of the entire
population and reduce the potential level of health inequality. this focus will also enable
the analysis of the complexity and comorbidity levels of the population, and its segmentation
with the aim of targetting resources to cover the different needs in a tailored and proactive
way.
Context and Focus
this policy recognises both the diversity of the social, economic and environmental factors
which influence the development and evolution of chronic illnesses, and the behavioural
factors which affect health. it also helps identify how these causes determine the inequalities.
in this way the specific needs of the different levels of the patients in question are responded
to: from those who are in the final phase of their lives (receiving palliative care) to those who,
although not yet chronically ill, present a series of risk factors which identifies them as potential
chronic patients in the future; as well as recognising and facing up to the specific requirements
of population groups such as the elderly and those who find themselves in a precarious social
30

33. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
or economic situation (the groups most affected by chronic illnesses and in need of specific
social interventions).
focussing the policy in this way, the prevention and care for chronic illnesses must respond
to the needs of the people from all backgrounds, both cultural and linguistic; of every age,
from children to the elderly; from all socio-economic classes; from all areas, both rural and
urban, and with no disparity between men and women.
Specific Results
the result of this policy will be to identify the “target” groups of patients for certain
interventions. this requires both a stratification of the population according to their clinical
risk and their health and socio-health needs, and also the association of each level of
stratification and patient typologies with the kind of interventions that evidence has proven
to be effective for chronically ill patients in the Basque country. eventually, this will all
be integrated in information systems and in the daily clinical duties of the medical
professionals, thereby personalising the treatment received by each patient.
this integration is fundamental, as the stratification of the population and the population
focus which it enables is a first essential step towards setting in motion the rest of the
chronic illness management policies.
furthermore, stratification will help bring about the change in mentality from a “patient”
focus to a “population” focus which considers the individual beyond the acute episodes
and also embraces prevention, rehabilitation, and medium-term care.
Table 11
Diagram of a possible pyramid of population stratification
Patients with severe complexity
Requires urgent health care coordination
Level 4
ies
vit
Patients with medium level complexity
cti
Level 3 Suffer from complications and need
na
a certain level of management
tio
en
Patients with reduced complexity
ev
Level 2 Well managed
Pr
Recently diagnosed
Patients with no chronic illnesses
Level 1 Healthy population
Source: Adaptation of the kaiser Permanente risk stratification
31

34. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
POLICY II. Prioritisation of health promotion and the prevention of illness.
Objective
A considerable number of chronic illnesses and their risk factors can be prevented and,
consequently avoided. once they are present, their early diagnosis and detection often
enables their progression and their negative and disabling effects to be limited. the
objective of this policy is to create a framework of action, including proactive prevention
measures and health promotion actions with regard to chronic illnesses, aimed at the
different levels of the population pyramid: both for the healthy and for those persons with
risk factors, as well as those who are already suffering from one or more chronic illnesses,
but always emphasising an integral population approach.
Context and focus
Specifically, some risk factors such as the consumption of tobacco, alcohol, or other
drugs, lack of physical activity, a badly balanced diet or unhealthy working conditions
can be controlled, thereby avoiding the appearance and progression of a high proportion
of many chronic illnesses.
the aim, therefore, is to put tried and tested measures and interventions into action with
the aim of preventing chronic illnesses. interventions will be combined both at an individual
level and at the level of patient groups and risk groups. the proposal of specific
interventions for health promotion and prevention of chronic illnesses must, necessarily,
take into account the available scientific evidence. thus, the use of information systems
and risk stratification of the attended population may be of great benefit when it comes
to carrying out interventions at a more efficient level.
health promotion actions must be aimed at raising awareness and informing the citizens
about their health, at improving their lifestyle habits, at raising their awareness with regard
to certain risk factors. As far as prevention actions are concerned, these must be introduced
both at primary and secondary level care, stressing the usefulness of early detection in
primary care and the capacity for contention of progression of the illness in secondary
care.
Specific results
resulting from the policy will be an integrated set of prevention and health promotion
actions of proven effectiveness in the Basque country, both at primary and secondary
level, aimed at target groups of patients according to the results of the stratification. these
actions should significantly reduce the prevalence of chronic illnesses and the deterioration
in health of those patients who suffer from them.
POLICY III. Promoting the active role of the citizens, encouraging their responsibility in
the management of their disease and in patient autonomy
Objective
Promoting the increasing role of the citizen in dealing with chronicity. on the one hand, with
self-care on the part of the chronic patients and their carers, as an essential lever to reach
personalised based care with the necessary support of the healht care system at all levels.
Self-care requires the active participation of the patients and their carers in administering
healthcare and in the process of making informed decisions which are agreed on with the
doctor, the patient and the carer. on the other hand, it requires their active participation in
their own health promotion and the prevention of the appearance and development of
chronic illnesses.
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35. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
Context and focus
care which is focussed on the individuals places them at the centre of their own health
care, converting them into active patients and administrators of their own state of health.
however, the traditional role of the patient and the carer in the health system is passive
with all the responsibility and knowledge centred on the doctor. this traditional role is up
to a point coherent from the point of view of acute illnesses in which immediate and
decisive action is required in the case of a complex episode in which the patient only
occasionally participates. A chronic procedure, however, has long reaching effects and
requires intervention over a long period of time. Moreover, the patient or carer has
considerable influence over the effectiveness of the treatment and the progression of the
illness depending on the rigour with which the treatment is adhered to and the lifestyle
of the patient (e.g. tobacco, exercise, obesity).
therefore, it is crucial to change the conventional role of the passive patient, receiving
care from the system, to that of an active patient/citizen, accountable for their own care
and illness prevention.
of course, the degree of participation and accountability of patients and carers is different,
depending on the type and complexity of the process, the level of independence, and
the social-health situation of the patient. in any case, all patients and carers have the
opportunity to participate in their care to an extent, as patients can be supported in the
development of specific skills and resources in order to maximize their capability for self-
care.
Specific results
the specific result of this policy will be an array of interventions and tools which will enable
self-management and promote the accountability of patients with regard to their own
condition. these interventions and tools will be incorporated into the daily clinical routine
of the health professional –and in that of the social workers when relevant- and will be easily
accessible and extensively used by the patients and their carers, with the support of patients
associations. the eventual consequence will be a stricter level of adherence to the treatment
and lifestyles necessary to control and prevent the illness, and a more efficient use of the
resources of the health and social systems.
POLICY IV. To guarantee continuous care through the promotion of a multi-disciplinary
care programme, co-ordinated and integrated between the different services, care
levels and sectors.
Objective
care for citizens suffering from chronic pathologies involves numerous health care providers
in different scenarios, such as Primary, Secondary and tertiary care, medium and long
stay rehabilitation centres with a focus on acute and sub-acute cases, mental health
centres, the social-health sector, health at work, community organizations and ngos,
etc.
integration and continuity in the provision of care are essential elements with which to
guarantee that the necessary services are received at the right time and in the right way,
optimizing health results and improving the experience of “the journey through the system”,
in a process which begins with initial prevention and goes beyond the worsening of a
chronic illness until the point at which rehabilitation permits the citizen to resume a normal
life. from the professional point of view, the target is to promote coordination to avoid
duplication and to reach optimum management with regard to transitions between care
levels.
33

36. A StrAtegy for tAckling the chAllenge of chronicity in the BASque country
Context and focus
this requires a flexible system, capable of coordinating services, suppliers, locations and
sectors over time. this, in turn, requires a commitment from all actors and the capacity
to work in a team in order to achieve common objectives.
the provision of services must be programmed and coordinated in order to attend to the
needs of patients and carers, in accordance with quality standards and clearly defined
care procedures (e.g. promoting the application of medical guidelines). the existence of
multidisciplinary teams, shared care tasks, skill training for professionals, and the taking
on of new roles are fundamental to ensure the effectiveness and the continuity of patient
care.
in short, the key for a system organized to improve planning, integration and continuity
of chronic patient care should revolve around:
• the coordination-integration of care measures.
• the promotion of multidisciplinary teams.
• the development of a model of subacute hospitals.
• Strengthening the role of Primary care.
• care planning.
• the design and effective introduction of new professional roles and profiles.
• Strengthening rehabilitation as a key pillar in the system.
Specific results
the specific result of this policy would become evident in all those mechanisms, roles,
social - health care agreements, clinical procedures/protocols/paths and tools which are
necessary to guarantee continuity of care for the chronic patient between the different
people and organizations involved, both health and social, and in particular during the
transitions between different levels of service. in a practical way, virtual multidisciplinary
teams would be set up which would share information and diagnoses in a transparent
fashion. the eventual consequence for the citizen would be care which was better adapted
to their needs and their situation within the cycle of the illness (from prevention to
rehabilitation), a product of the integrated vision of the information and the reduction of
the number of unnecessary interactions, caused by the lack of coordination between care
levels, while the health professionals and social workers take on new roles which will enable
them to focus on improving the health and the situation of the patients, and to avoid
repetitive work and carrying out tasks of minor added value.
POLICY V. To adapt the health interventions to the needs and priorities of the patient
and the efficiency of the system.
Objective
to develop a patient centred system which chooses the optimum health intervention from
a wide range and adapts it for the chronic patient in each situation, taking into account:
• in first place, the needs and priorities of the person, bearing in mind that behind each
medical record there is an individual with a series of personal, emotional, social and
psychological needs, seeking the most humane care and that which is less aggressive,
disruptive and intrusive for the life of the patient (e.g. a ten minute visit may require
up to four hours of disruption in the patient’s life) with special emphasis in the case
of those patients in palliative situations.
• in second place, the needs and priorities of the patient, their carers and their
environment, with an integrated vision of their pathologies, progress and previous
34