2 out of 3 people of retirement age live with at least 2 chronic diseases. 80% of them are users of some kind of health services or social resources. However, Care Plans (medical) usually exclude Municipal Social Services, and they operate asynchronously and in parallel. Due to its proximity with the local society and residents, if municipal social services detect any relevant situation, communicate to the medical team attending the patient, so that they can adapt and optimize the Care Plan, but usually they find themselves with insufficient channels to advise the medical team, depending in most cases, on a communication offline and paper based to support the care circuit.
On the other hand, users of social and health services must follow a long bureaucratic chain to initiate the processing of the resources to which they are entitled. And once they got it, neither the patient nor the family can participate in the care circuit, leading to confusion, demotivation and a poor quality perception of the service received.
In this context, the adoption of a Care Coordination model (through integrated health and social care teams) represents a double opportunity: on the one hand, to optimize public resources for the care of people with chronic diseases or in situations of dependency and, on the other, moving towards a more effective care, focusing its attention on people (patient-centred care) and their needs and based on the generation of a new culture of care. This momentum should be used to press ahead with vigour to allow the socio-health coordination become a true reality in our country putting us at the forefront of the health systems.
What is Governalia
Governalia Socio-Sanitary Coordination is a proactive model allowing Municipal Social Services to collaborate jointly and in an integrated manner with health services in order to ensure continuity, quality and equity in users care. This model is characterized by prevention, care and monitoring of socio-health patient, after an initial assessment and Care Plan allocation and customised tracking of actions. All this in order to progress in the provision of better profiled services, according to the particular needs of people and in order to alleviate the financial and economic burden for the system services.
Moreover, Governalia Socio-Sanitary Coordination allows integration with Governalia Folder “Health for All”, converting the patient and the caregiver in active actors of the Care Plan, participating in many of the activities and self-management of their own health and welfare, enhancing the independent life of patients and their empowerment.
What is Governalia
The basic features of Governalia model Socio-Sanitary Coordination, are the coordination at all levels of the organization, a single gateway to services, the figure of the Case Manager that evaluates, plans and organizes care actions; individualized service plan designed by the program manager, as valuation tool and a computer system that allows to obtain and update clinical information.
- Homogeneous Planning of Care Protocols for all providers (primary, hospital, social services, etc.) allowing the deployment of specific Care Plans and sharing Care pathways designed to target an objective population.
- Customising Care Actions for each patient based on their clinical profile and specific and individual needs.
- Multidisciplinary Teams working in a proactive care, creating a more effective model so much in spending as a more integral attention to people, putting the patient at the centre of the joint actions and coordinated services.
- Scheduling of welfare activities of all suppliers, establishing the responsible, the frequency and the result.
- Specific Material to support the patient and family carers through information and training initiatives that enable prevention and awareness of own self-care.
- Dashboard allowing to monitor and measure the compliance of objectives established through indicators definition and normality threshold in relation to care activities, clinical evolution, management policies, etc.
- Integration with other complementary applications already implemented (or that are going to be implemented) in the Municipality or Autonomous Community (SISAAD, SIUSS, etc.) for synchronizing information in real time without the need to maintain parallel applications.
- Especially designed for integration with Governalia Folder “Health for All”.
- Quart de Poblet (Local Council).
- Manises Hospital.