The 1.1.2015 Integrated Health Organization (OSI) Donostialdea was formed, as a result of the union of the region integration result Gipuzkoa Primary Care (part) and the University Hospital Donostia Health Organization. It is responsible for providing comprehensive community health services to 360,000 people living in 17 municipalities, along with five centers Mental Health Network of Gipuzkoa and 3 Regions of public Health, and other institutions and public and private actors.
Gipuzkoa The Region has had a journey through time in promoting and strengthening communication and joint work between primary health care and social services. The importance and dedication from the address Shire in this area resulted in the formation of an internal structure and related professionals responsible for care coordination. there is a reference figure geriatric nurse in all primary care units and since 2012 there is a social worker in charge of this issue in the region.
The objectives proposed in recent years have been aligned with the regulations, action plans, and documents published consensus (LAPAD, Social Services Law, Framework Document for care coordination in the Basque Autonomous Community, Health Plan of the BAC, Lines strategic and action- plans Osakidetza 2013-2016, strategic Lines of geriatric care for Euskadi 2013-2016 ...)
In this context, they have been launching experiences that take into account the strengthening of domicile as the main recipient of care. It has been chosen to develop a model of care coordination protocol focused on primary care, but which also includes hospital and specialized care. Actions are being developed around the health promotion and prevention of dependence; attention to personal needs derived chronicity, old age and dependency, and those arising from situations of vulnerability and exclusion. This implies working together with an increasing number of institutions and entities: Municipal and Provincial Social Services; various municipal departments (Sports, Gender, Culture ...); Branch Public Health and Addictions; Education deparment; Ertzantza; third sector companies; elderly associations and affected ...
At the University Hospital Donostia, the Admissions and Clinical Documentation functions include patient management, allocation of adequate level of care in the health area of Gipuzkoa, through a comprehensive assessment. To make this work clearly socio orientation, SADC has a section dedicated to the assessment and monitoring of geriatric patients in both the hospital and the community. This is a team of geriatric interdisciplinary comprehensive care. This team has participated since its creation in the Sociosanitaria Commission Assessment and Orientation of Gipuzkoa and in different programs and protocols of care coordination aimed at children with special care needs, people in situations of vulnerability and exclusion, and discharge planning hospital.
Clinical Management Unit and Chronic Convalescent Patient develops an important role in ensuring the continuity of the social care of these patients in their usual residence with different performances of reference for primary care and residential centers.
The first step in this process has been to design a public health / health promotion of this new organization plan after analyzing what was already being done, in order not to keep so disjointed interventions that can generate duplications and / or welfare gaps. From there it has begun building with a unique view given the multiplicity of sectors, levels and actors involved in the socio space.