{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T11:45:29Z","timestamp":1782819929196,"version":"3.54.5"},"reference-count":44,"publisher":"Ubiquity Press, Ltd.","license":[{"start":{"date-parts":[[2026,5,26]],"date-time":"2026-05-26T00:00:00Z","timestamp":1779753600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Catalan University and Research Department","award":["2024DI00069"],"award-info":[{"award-number":["2024DI00069"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Int J Integr Care"],"abstract":"<jats:p>Introduction: Person centred care planning and models of care coordination across levels of care reduce fragmentation and unnecessary resource use. Our objectives were to assess the impact of implementing a coordinated care model between intermediate care and primary care, as determined by the identification of complex patients, and recording their individualized care plans in the shared medical record and to assess its effectiveness in relation to the use of health resources.\nMethods: A pre-post quasi-experimental study of 160 complex patients with dementia who were discharged from intermediate care between April 2022 and July 2024.\nResults: A 31.4% (from 63 to 106 patients) increase in the identification of complex patients with dementia and a 23.6% (from 19 to 44 patients) increase in the development of care plans were found at 3 months of discharge. Of the patients who had visited emergency department in the six months preceding hospitalisation, 54.4% (n = 31) did not visit it in the six months post-discharge (p = 0.026).\nConclusion: Our coordinated care model may have contributed to improved identification of patients with dementia and complex conditions, the development of individualized care plans, and reduced emergency department use.\n\u00a0\nResum\nIntroducci\u00f3: La planificaci\u00f3 de l\u2019atenci\u00f3 centrada en la persona i els models de coordinaci\u00f3 assistencial entre nivells assistencials redueixen la fragmentaci\u00f3 i l\u2019\u00fas innecessari de recursos. El nostre objectiu va ser avaluar l\u2019impacte de la implementaci\u00f3 d\u2019un model d\u2019atenci\u00f3 coordinada entre l\u2019atenci\u00f3 interm\u00e8dia i l\u2019atenci\u00f3 prim\u00e0ria, determinat per la identificaci\u00f3 de pacients complexos i el registre dels seus plans d\u2019atenci\u00f3 individualitzats a la hist\u00f2ria cl\u00ednica compartida, aix\u00ed com avaluar-ne l\u2019efectivitat en relaci\u00f3 amb l\u2019\u00fas de recursos sanitaris.\nM\u00e8todes: Estudi quasi experimental pre-post de 160 pacients amb complexitat i dem\u00e8ncia donats d\u2019alta de l\u2019atenci\u00f3 interm\u00e8dia entre abril de 2022 i juliol de 2024.\nResultats: Es va observar un augment del 31,4% (de 63 a 106 pacients) en la identificaci\u00f3 de pacients complexos amb dem\u00e8ncia i un increment del 23,6% (de 19 a 44 pacients) en l\u2019elaboraci\u00f3 de plans d\u2019atenci\u00f3 als 3 mesos de l\u2019alta. Dels pacients que havien visitat el servei d\u2019urg\u00e8ncies en els sis mesos previs a l\u2019hospitalitzaci\u00f3, el 54,4% (n = 31) no el van visitar en els sis mesos posteriors a l\u2019alta (p = 0,026).\nConclusi\u00f3: El nostre model d\u2019atenci\u00f3 coordinada pot haver contribu\u00eft a millorar la identificaci\u00f3 de pacients amb dem\u00e8ncia i condicions complexes, el desenvolupament de plans d\u2019atenci\u00f3 individualitzats i a reduir l\u2019\u00fas dels serveis d\u2019urg\u00e8ncies.\n\u00a0\nParaules clau: atenci\u00f3 integrada; gent gran; dem\u00e8ncia; multimorbiditat; fragilitat; atenci\u00f3 centrada en la persona<\/jats:p>","DOI":"10.5334\/ijic.10026","type":"journal-article","created":{"date-parts":[[2026,5,26]],"date-time":"2026-05-26T08:36:58Z","timestamp":1779784618000},"page":"15","source":"Crossref","is-referenced-by-count":0,"title":["Evaluation of the Impact of a Coordinated Intervention Model for Complex Older Patients with Dementia"],"prefix":"10.5334","volume":"26","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2601-469X","authenticated-orcid":false,"given":"Matilde","family":"Barneto-Soto","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0138-6278","authenticated-orcid":false,"given":"N\u00faria","family":"Molist-Brunet","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5510-2480","authenticated-orcid":false,"given":"Emma","family":"Puigoriol-Juvanteny","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-7718-6275","authenticated-orcid":false,"given":"Anna Ribera","family":"Nadal","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4390-4697","authenticated-orcid":false,"given":"Rosa Mar\u00eda Torres","family":"Allepuz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7057-0901","authenticated-orcid":false,"given":"Joan","family":"Espaulella-Panicot","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"3285","published-online":{"date-parts":[[2026,5,26]]},"reference":[{"issue":"18","key":"key20260526083653_B1","article-title":"Characteristics and service utilization by complex chronic and advanced chronic patients in catalonia: A retrospective seven-year cohort-based study of an implemented chronic care program","volume":"18","year":"2021","journal-title":"Int J Environ Res Public Health"},{"issue":"1","key":"key20260526083653_B2","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1093\/epirev\/mxs009","article-title":"Multimorbidity in older adults","volume":"35","year":"2013","journal-title":"Epidemiol Rev"},{"key":"key20260526083653_B3","first-page":"143","volume-title":"Risk Management and Healthcare Policy","year":"2016"},{"key":"key20260526083653_B4","first-page":"8","volume-title":"BMJ Open","year":"2018"},{"key":"key20260526083653_B5","unstructured":"Com I. 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