Title: Strategic Intelligence Monitor on Personal Health Systems Phase 3 (SIMPHS 3) – Integrated care programme for older in- and out-patients, University Hospital of Getafe (Spain) Case Study Report

For more than 20 years the Geriatrics Service of the University Hospital of Getafe (Hospital Universitario de Getafe – HUG) has been offering integrated care programmes for older in- and out-patients. These services provide continuous, progressive and coordinated attention to patients at high risk of functional decline, institutionalisation, and hospitalisation, at home or in residential care settings. The objective is to offer the most appropriate care according to the changing needs of the patients. The programme is twofold: for people admitted to the hospital, the care teams responsible for the different phases of the treatment are coordinated through periodic meetings (both physical and remote, the latter to coordinate care with other hospitals) and coordinate with the team in primary care before discharge; for patients who are at home or in residential care facilities, the programme includes follow-up of the patient directly, or in close collaboration with primary care and social care agents when needed.