[Program to improve care in chronic illnesses: application of the model of care in chronic illness]

Chronic diseases have become more central to Primary Care due to their greater prevalence and the difficulties of monitoring them. This complex problem requires a many-sided solution that affects patients' behaviour, health workers' approach and changes in how the health service is organised.

The Chronic Diseases Care Model aims to empower the patient to manage his/her own disease and to encourage doctors to take a proactive approach. PROGRAMME: The model proposed has six interlinked components, focusing on the patient. A personalized care plan, based on the scientific data, is worked out. All patients are followed up, including those not attending for consultations. The model possesses a specific tool for exploring possibilities of improvement and incorporates the P-D-C-A cycles in order to make changes in activities.

The Health Service's emphasis on resolving acute problems is the biggest barrier to the Model's introduction. Selection of those patients who will most benefit and the visible support of system leaders are key elements for the Model's success.