Individual and Integrated Care Plan in Clinical Relation

Abstract

Socio-cultural and technological advances have created a
new paradigm of living and dying. Chronic disease, often
multiple and complex, creates prolonged states of vulnerability and dependence on health professionals. This vulnerability comes from a set of listable, time-consuming and
changeable needs. This renewed sense of medical professionalism is based on new methodologies for the chronic
condition and complexity management. We discuss and prepare the concept of Individual and Integrated Care Plan as a
reconciliation of multiple plans responding directly to specific needs. Planning is patient-centered, circumscribed to its
intrinsic value as a human being of unrepeatable historical
relevance, in its preferences and diversity, and projecting it
into the future, where its anticipated needs are bridged by an
interdisciplinary team. Implemented support is adjustable to
patient / family status change. We consider this work tool to
create a solid framework in approaching the frail and complex patients.