Where are we headed? Route for dementia care

Our population is growing older and the resources are limited; in order to be able to maintain the sustainability of the public health system, a new management line is implemented that is framed in the strategic lines of the 2013-2016 Health Plan. The second strategic line: integration, integrated response to chronicity, ageing and dependence. The OSI Bilbao Basurto is a recently created organisation and it is comprised by two organisations and two different cultures: Primary Care Bilbao University Hospital Basurto It is constituted with clear objectives: Reorient the functions of the different care levels and adapted the healthcare service to the health needs of the population And in the centre of all our population, using the resources of both healthcare and social areas in the most efficient forms. Developing the socio-healthcare space where the patient can be seen in an integral way, in the biopsychosocial aspects. To achieve this, we have set the creation of protocols and healthcare routes that provide us the communication and the relation of the two care areas and professionals of the social areas. As an example, we present you with the dementia healthcare route. Dementia is a social and healthcare problem of enormous magnitude. It affects a large proportion of the elderly that usually present other health problems. The disability that it produces is progressive and impacts the health and quality of life of the patient as well as the caretaker, who usually is also elderly. For this reason, dementia represents the paradigm of the necessary coordination between care levels and social workers. The care model for the inter-level and social coordination in the home environment for the detection and early diagnosis of dementia and its symptomatic treatment, clinical monitoring of the patient’s and caretaker’s health, and social support to the patient. Results : A distribution of functions and a reference-communication circuit between all the levels supported in 5 documents of own or modified elaboration.