The aim of strategy is to merge hospital and primary care structures under one single organization, focusing on clinical and functional integration.
The strategy deploys an integrated care model capable of providing continuity of care both at health and social care levels. Beneficiaries are aging people, patients, social workers and Nursing homes. It is focused on people and patients. The main actions are:
 Health Care Integrated Plan: Implementation of a model of Integrated Healthcare Organizations (OSIs) with Joint Governance bodies for primary care and hospital, with a defined population catchment area.
 A unified and shared clinical information system (Osabide Global) supporting the integrated care strategy.
 A population risk stratification strategy identifies patients with different levels of complexity according to the likehood of using healthcare services in the near future.
 Integrated Intervention Program for multimorbid frail patients.
 Care Pathway integrating Hospital, Primary Care and Social professionals.
 Strategic Social and Health Care guidelines for BC, 2017-2020.
 Interoperability of social and health information systems, to share the diagnosis and care plans.
 Scaling up of Osabide and Presbide to all services.
 Extension to nursing homes to facilitate the communication between health professionals and ensure shared clinical information.
 Patient and caregivers empowerment by means of Active Patient, Osasun Eskola, Kronik ON programs.
 Budget Impact Modeling Analysis to manage continuous improvement in the implementation of integrated healthcare for multi-morbid patients.

Resources needed

According to Eustat (Basque Institute of Statistics), the Total Public Health budget in 2016 is 3.427,5 M€, the 31,4% of the Basque Government’s total budget (10.933,3M€). Chronic diseases accounts for 80% of the 3400M€ Health expenditure in 2015.

Evidence of success

New complex patients identified
Less hospital days for multimorbid patients with a readmission rate decreased 16.7% from 2014.
Increase in nursing home visits.
New projects underway with a community approach.
> 300 training courses for patient activation.
Features of 39% indicators implantation (2017):
Objectives (O) and action (A) in the plan already started (>89%). In detail:
oO and A ready,>31%.
oOs with an improved in the development,>14%.Os with a worse development,>,>14%.

Difficulties encountered

Difficulties|Healthcare practices are stable (laws, interest groups, information systems, and network of influences). Lessons|Involvement of decision-makers, professional (uptaking new task and skills) and stakeholders, patient and informal caregiver to define care pathway.

Potential for learning or transfer

The fragmentation of a Healthcare system is a significant impediment to effective care of chronic patients, who require long-term treatments from different medical professionals. This GP represents an example of how to build up a coordinated public healthcare and social care system which are often both required for chronic patients and which it turns essential among the elderly. The Basque Government launched in 2010 the strategy integrating care policies in order to transform healthcare organizations into more integrated care models, with the aim of improving quality and efficiency in their management. This effort shows how to create 13 Integrated Health Care Organizations (IHOs) under the same structure Primary and Secondary Care Services. Besides, several initiatives have been launched in order to improve coordination and continuity of care under the plan including a clear implementation and evaluation of the strategy.
Main institution
BIOEF - Basque Foundation for Health Innovation and Research
País Vasco, Spain (España)
Start Date
January 2010
End Date


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