Interdisciplinary meetings in Primary Care (PC): Organizational experience in the PC team to obtain health results

The person-centered care model requires a comprehensive and integrated approach by an interdisciplinary team. The intervention of all disciplines allows for a biopsychosocial approach to the person and their environment, considering all social determinants of health. Objectives: To establish systematic periodic meetings to facilitate the evaluation and improve the care process of a specific group of patients, as well as coordination between different professionals and care areas. Description: In an AP team, there is a need to initiate this methodology in which a doctor and a nurse who have a quota of patients whose adjusted morbidity degree (GMA) 4 is 91 patients and 284 GMA3 patients, of which 135 are identified as complex chronic patients (PCC) and 18 advanced chronic patients (PCA). With the intention of guaranteeing continuity of care, integrated care and facilitating coordination between care levels, we started meetings, on a monthly basis, between the basic AP team, following the following methodology: The reference team after home care with comprehensive assessment of the patient, their family and environment, proposes the case and presents it. With the social worker and the community case manager nurse (EGCC), they will agree on a date for the meeting, on an agenda scheduled with the cases agreed to be discussed, with a total time of approximately 60 minutes. The current situation of the case will be described, and the objectives established by each professional, with the patient's and/or family's willingness, their capacities and viable resources. The rest of the professionals expose their interventions and work plans up to that moment or establish the possible courses of action to be agreed with the patient and/or family. The social worker, if necessary, will coordinate with the rest of the social resources. The EGCC will establish a link with the rest of the care levels, as well as proceed to manage the necessary resources. In the next meeting, a work plan is agreed upon for each professional and these tasks will be reviewed at the beginning of the next month's meeting.Results and conclusions: An integrative approach is achieved with improvement of clinical and social parameters of the patients addressed, which benefits the user, their family and the referring AP team