Personal Recovery Plans (PPR) in Community Resources for Severe Mental Disorders (SMD) platform.
About this good practice
People with Severe Mental Disorders (SMD) face significant challenges in social and work inclusion, as well as accessing comprehensive care that addresses their specific needs. These difficulties are worsened by population aging and limited coverage in rural and underserved areas. The implementation of Personal Recovery Plans (PPR) addresses the need for a personalized model that coordinates healthcare and social services within a community framework, incorporating digital technologies to expand reach and ensure equitable care.
The PPR platform provides a method of collaboration between healthcare professionals and social workers from Aragón Healthcare Service Provider (SALUD) and professionals from collaborating partner social entities. Its main objective is to manage personal rehabilitation plans for patients referred from SALUD, by creating a comprehensive database of the patient's social information and a continuous monitoring system of their rehabilitation process.
Main stakeholders are SALUD, collaborating entities, local administrations, & end-users, while beneficiaries are people with Severe Mental Disorders (SMD) and their families.
The goal in this initial phase is to solidify implementation, ensuring resources reach those most in need, strengthening the strategy's foundation and building trust in the model for future expansions.
Resources needed
Financial Resources: Framework agreements regulate available slots, facilitating collaboration between institutions for program development.
Human Resources: Psychiatry teams, social workers, rehabilitation entities, EHR-PPR coordinators, and IT technical support.
Evidence of success
The program has enhanced coordination between devices and entities, effectively reaching older adults and underserved areas. It has increased autonomy and satisfaction for patients and families, while reducing prolonged hospitalisations. 80% activation via the eHR. More than 80% social entities have adhered to program.
Potential for learning or transfer
The PPR model has demonstrated its replicability. Initial challenges in collaboration between health and social sectors transformed into opportunities for robust cooperation. ICTs play a crucial role in rural areas with aging populations, ensuring continuity of care through EHR interoperability. Despite geographical dispersion and professional shortages, technology and coordination remain vital. The program also facilitates studies with specific mental health indicators, driving evidence-based improvements and informed decisions.
It is based on national strategies to promote healthcare information interoperability, integrating essential data and achieving full integration in European EHR interoperability projects.
PPR aligns with the Aragón Mental Health Strategy, part of the Aragón Health Plan, &the National Health Plan. It shares objectives with the European Mental Health Plan, reinforcing international standards. It focuses on rural and underserved areas, ensuring equitable care.