The Andalusian Government has announced a profound reorganization of Primary Care with the aim of adapt to the specific needs of people with chronic illnesses, through a new strategy presented this Tuesday at the Andalusian School of Public Health (EASP) under the name of the Andalusian Plan for Chronic Care (PAdAC).
The Minister of Health and Consumer Affairs, Rocío Hernández, was responsible for detailing this initiative, which will include the collaboration of the Andalusian Health Service (SAS). Hernández emphasized that the goal is to offer more accessible, proactive healthcare tailored to the profiles of patients with chronic diseases, incorporating not only medical follow-up, but also a social and emotional approach from a biopsychosocial perspective.
"The reform will improve accessibility and care for patients with complex chronic conditions, establishing a comprehensive response from Primary Care.", explained the counselor, who participated in the presentation via videoconference.
Changes in the healthcare organization
The PAdAC proposes a substantial change of the Primary Care assistance model which will be implemented progressively starting this year. This new model contemplates reorganized care for both deferrable demand and acute episodes of decompensation in people with chronic diseases stable.
Among the planned measures is proactive follow-up by the medical-nursing team and nurse case managers, always in collaboration with the social worker. This model aims to Improve the patient's environmental conditions and provide direct support for home care, ensuring more personalized attention.
The plan also includes the redesign of inpatient consultations, specific training for healthcare personnel, and the implementation of teleconsultation tools, which will be integrated before the end of 2025.
In addition, progress will be made in the creation of Shared Care agendas focused exclusively on the chronic diseases, with care times reserved for monitoring and comprehensive care, thus avoiding fragmentation of care.
A challenge for the aging population
Hernández recalled that the plan responds to "One of the major challenges facing the Andalusian Public Health System: progressive aging and the increase in life expectancy, which currently stands at 82 years.".
According to data from the Institute of Statistics and Cartography of Andalusia, the most prevalent health problems in 2024 are precisely the chronic diseases, with a particular focus on dyslipidemia, hypertension, osteoarthritis, anxiety disorders, and asthma. Other less prevalent conditions are also identified, such as diabetes, hypothyroidism, obesity, and chronic obstructive pulmonary disease (COPD).
Person-centered strategies
The PAdAC is structured around five key strategic lines. The first of these focuses on "learning to take care of ourselves from childhood", reinforcing the promotion of healthy lifestyle habits from Primary Care, led by nurses specializing in Family and Community Nursing.
The second line addresses personalized attention, where people with disabilities will be grouped together. chronic diseases based on homogeneous needs profiles, establishing standardized clinical pathways at the local level. Furthermore, the gradual integration of pediatric patients into adult units will be promoted, in line with programs such as the Andalusian Child and Adolescent Health Program.
The third strategic line seeks Improve care for patients with complex chronic conditions through an anticipatory and proactive approach, with specific prioritization criteria for both adults and children. This measure will be reinforced with home care, the creation of Continuity of Care Units, social and health coordination, and support for caregivers.
Research and innovation at the service of chronicity
The fourth strategic line promotes the Research, innovation and knowledge transfer in the field of chronic diseasesThe participation of healthcare professionals in research projects, the creation of collaborative networks, and the dissemination of key results will be encouraged, in addition to establishing training programs aimed at improving care for these conditions.
Finally, the fifth line positions digital health as an ally in caring for chronic diseases, with actions such as the protocolization of the use of telemedicine, the incorporation of decision-making support systems into electronic medical records, and the integration of health data generated by the patients themselves.
"Digitization will facilitate self-care and enable faster and more efficient responses to people with chronic illnesses.", Hernandez highlighted.
The counselor concluded by pointing out that the implementation of the PAdAC is based on A collaborative approach that involves both healthcare professionals and citizens, promoting shared responsibility for the health of each individual..
