Chronic Patient Program – Badalona Serveis Assistencials

Good practice:

Foster good relationships between different care providers and specialities

CATALONIA  / Chronic Patient Program - Badalona Serveis Assistencials:  162/381 9/25

Badalona Serveis Assistencials (BSA) is an integrated private care organisation. BSA is entirely funded by public capital, and manages one municipal hospital, integrated home care services, one intermediate care hospital, seven primary care centres and a centre for sexual and reproductive health.

BSA provide care for 419,797 inhabitants in a very populated suburban area of Barcelona (Spain). BSA has been responsible for health and social care services in this area since 2000. The Badalona’s City council included social care under the BSA service provision. This fostered a new model that would put the needs of citizens and patients at the centre of the system. Within this context, BSA launched the Chronic Patient Program.

Customer's need

The Chronic Patient Programme plans and carries out interventions. The focus is to identify, prevent and treat. Particularly with the reduction of acute episodes.

The solution

The programme helps to:
• Avoid further hospitalisations.
• Evaluate each particular need to design and implement individual integrated care plans.
• Include general geriatric evaluation.
• Promote independent living for patients, while maintaining good quality of life.
• Coordinate the work of the interdisciplinary teams doing the interventions.

BSA developed an institutional and organisational model with policy support. With a commitment that facilitates full integration. It includes fully integrated services. These cover: the continuum of care and the work across tiers of care with a multidisciplinary team of specialists, general practitioners, nurses and social workers, occupational therapists and physiotherapists.
This organisational innovation is aligned and supported by technological innovation. BSA EHR is a fully interoperable information system. It enhances communication and information flow across the continuum of care. Supporting health and social care professional practice.

Keys to success

  • The key user role is taken by clinical champions. Serving as an example, they spread the engagement to the rest of the professionals.
  • Interoperable information systems are a key factor for full deployment of integrated care.
  • Policy support and commitment will facilitate organisational processes. Together with governance mechanisms for the deployment of the programme.

Good practice: Foster good relationships between different care providers and specialities

Good practice description

Healthcare professionals described a range of approaches to encourage strong relationships between different specialities and organisations. This is based on an acceptance of the need to work in new ways to deliver support beyond conventional care settings and within patient’s homes. This encourages more fluid boundaries between professionals and areas of work overall.

“Provide individualised care for people with complex needs by offering coordination with specialised care teams.”

Good practice example

Strong relationships were forged by building multidisciplinar care teams. BSA Programme is outstanding in terms of staff engagement — Specific drivers directly impacting upon patient outcomes are: interventions in training, early engagement of staff, introducing feed-back loops, and ensuring recognition of professional expertise.

The program

The main objective of the Chronic Patient Programme is to offer an integral care model through the provision of social and healthcare services. This is provided for patients with multiple chronic conditions, and is based on the optimisation and integration of resources. Resulting in a fast response time to the needs of the inhabitants in the region. In order to develop it, BSA has designed a predictive model. This allows the risk stratification of the population between care needs, which would arise during next year. The purpose is to identify patients in a proactive way, rather than wait for their institutionalisation. This model has a demographic focus, which has allowed BSA to organise its care units in order to provide a better service to chronic patients.

Using this model, together with multimorbidity and frailty criteria, BSA can identify the risk of each particular citizen. Helping to provide the best care to each individual.

Depending on the multimorbidities, BSA classifies the patients into different groups to adapt the needed resources:

  • Patients without any disease: Promotion and prevention.
  • One to two chronic conditions: Patient at risk: Self-empowerment.
  • Three to four chronic conditions: Medium complexity patient. Assisted care. Disease management.
  • Five chronic conditions: High complexity patient. Special care. Case management.

The main objective of the PPAC programme is to offer an integrated care model. Which is provided by social and healthcare services for patients with multiple chronic conditions. By optimising and integrating resources, they can respond quickly to the needs of the inhabitants in the region.

Contact information

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Sebastià Santaeugènia

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Jordi Piera




  • Badalona Serveis Assistencials (2013). Annual Report 2013
  • Strategic Intelligence Monitor on Personal Health Systems Phase 3 (SIMPHS3). Badalona Serveis Asssistencial. Case Study Report.; Joint Research Centre; Institute for Prospective Technological Studies. European Commission, 2015.h

Program partners