[Integrated approach to a complex chronic case through an interdisciplinary team in primary care]

This article tends to illustrate the coordination mechanisms used through an example centred on a case study of a 65 year-old patient who presents obesity, hypertension, high cardiovascular risk, alcoholism, smoking and silent ischaemic strokes; divorced twice and with five children. After his last separation 8 years ago he moved to his father's house. While his father was still alive his health situation was stable and monitored by professionals of the primary care team. He was recently referred to the Social Worker at the Health Centre due to his lack of personal hygiene and housing. The interdisciplinary work of the Social Worker and Community Nurse Case Manager resulted in a shared action plan. His father died a year ago and since then there was no news of the patient in the health centre and also he did not collect his medication from the pharmacy. The house was owned by inheritance by the smallest of the four brothers, who had threatened to expel him. In the interview, the brother claimed that he didn't want to be helped and only received visits from one of his sons occasionally to receive money. Primary care professionals visited him several times at home. The patient was cooperative and engaged when preparing a joint plan with the professionals involved. This joint plan allowed to activate the care coordination for a successful management of his chronic conditions.