Transforming health care through the development of the Strategy for the Care of Patients with Chronic Diseases in Madrid.

Introduction: The Strategy for the Care of Patients with Chronic Diseases entails the guiding element for the transformation of the entire health system, through the development of a model of care based on the needs of each patient, giving patients an active role in their health and their disease and developing for the more complex patients, a proactive and integrated care across the health and social system. For the success of this transformation, it is necessary to consider both the potential resistances centers experiences, serving as a platform for knowledge management and enhancing innovation. An ongoing assessment of the strategy is performed through indicators and the monitoring of projects is done periodically. Progress has been made in the identification and monitoring of impact indicators on chronicity taking as reference the Triple Aim. Comments on transferability: The development and implementation of health strategies can lead to profound transformations of health care and social systems. To make easier this transformation is important to identify and work on the various levers of change and facilitators that are common to all organizations Conclusions: The development and implementation of a strategy for the care of patients with chronic diseases can be the guiding element for the transformation of health and social systems. A change management vision is needed from its design and therefore requires work on cultural transformation, unifying and sharing the narrative, counting with all stakeholders, developing new enabling tools and sharing the experiences of change.

this deal according to the level of risk of each patient in a given time. The Strategy is structured in 9 lines of execution, which are being developed and deployed simultaneously.
To facilitate this, it is necessary to address the transformation starting from the design to the evaluation of the strategy, working simultaneously on different levers that become critical success factors from our experience and comprise: 1. Make visible the reasons for change and expected profits. 2. Clearly define the steps to take and therefore planning projects with tangible milestones that lead to the development of enablers of change. 3. Involve leaders in the design, development and implementation. 4. Work in the cultural transformation of politicians, managers, professionals and patients. 5. Facilitate and promote innovation and knowledge management favoring the identification and expansion of successful initiatives. 6. Strengthen the evaluation of the steps and achievements facilitating continuous improvement Targeted population: The target population comprises a total of 6,381,027 patients.
Highlights: During the strategy design, both the reasons for change and the desirable gains were visible, as well as the steps to take. 180 organizational leaders participated, besides patients.
A Monitoring Committee was established, led by the Deputy Minister of Health Care and different General Directors of the Health Counseling to ensure the development and implementation of the Strategy.
The deployment was structured through nine execution lines already being deployed across 23 planned projects, which include the milestones to be achieved, people responsible, timeline and indicators.
Dissemination and cultural transformation activities are manifold. 7 presentation conferences have so far been organized attending 3,000 professionals. A space on the intranet has been designed, created to establish a scientific forum to share experiences which had in the first 6 months 13,744 hits, and has produced an informative and divulgative newsletter called "Croninet" which is published monthly and reaches 1,180 professionals to inform and raise awareness of the new documentary, reviewing the evidence, or the most important news from inside and outside the community. During 2014, 63 Primary Care training activities have been initiated and the Formative Framework on chronicity has been established for the future. We have developed a map of chronicity initiatives that allows sharing among different health centers experiences, serving as a platform for knowledge management and enhancing innovation. An ongoing assessment of the strategy is performed through indicators and the monitoring of projects is done periodically. Progress has been made in the identification and monitoring of impact indicators on chronicity taking as reference the Triple Aim.

Comments on transferability:
The development and implementation of health strategies can lead to profound transformations of health care and social systems. To make easier this transformation is important to identify and work on the various levers of change and facilitators that are common to all organizations Conclusions: The development and implementation of a strategy for the care of patients with chronic diseases can be the guiding element for the transformation of health and social systems. A change management vision is needed from its design and therefore requires work on cultural transformation, unifying and sharing the narrative, counting with all stakeholders, developing new enabling tools and sharing the experiences of change.
Keywords organizational culture; chronic disease; health services administration