The event, held in the auditorium of the Cross-Border Cultures and Cooperation Center, highlighted the need for an integrated response to the increase in chronicity and complexity of diseases. In the Pla de Lleida region, approximately 15,000 people suffer from a complex or advanced chronic illness, underscoring the urgency of this approach.
The conference emphasized collaboration between primary care, hospital facilities, intermediate care, and the SEM, as well as the involvement of social services. This synergy has allowed for the development of the Chronic Care Route 2.0, a new model that seeks proactive care based on early identification and anticipated planning.
“"An integral and coordinated approach among all involved agents of the health and social system is essential for proactive chronic care based on early identification, multidimensional assessment, and anticipated planning."
The inaugural presentation, given by Ana Vena, territorial clinical director of Chronicity and Home Hospitalization, under the title Transforming to care: the new perspective on chronicity, emphasized the importance of teamwork and integration between different care levels, including the connection between rural and urban areas to ensure equitable care throughout the region.
During the session, topics such as early detection and complexity stratification were addressed, with the participation of professionals like Laia Ribelles, Maria Oro, and Gemma Fabregat. The Shared Individualized Intervention Plan (PIIC) was also presented as a planning tool, and continuity of care in mental health was discussed, with interventions by M. Àngels Costa and Joan Marc Dolcet.
The conference concluded with the presentation of territorial experiences and the testimony of a patient from the home care program, who highlighted the importance of placing the patient at the center of care to ensure effective care transitions.




