The Chronic Care Management Team


The Chronic Care Management Team (CCMT) is an expert multidisciplinary team forming part of the services of the  Gerència Territorial Metropolitana Nord de l’Institut Català de la Salut (ICS). The ICS is the main public health provider in Catalonia, including the Metropolitan area of Barcelona North, and it manages care for 70% of the population (up to 1,4M people from 71 municipalities), through  64 Primary Care Teams and the Germans Trias i Pujol University Hospital.



The CCMT was created in 2018 to construct new organisational models of care and to encourage value-based practices in chronic care in our area. It provides support to primary care and hospital care managers helping them to implement and evaluate integrated care initiatives at meso level tailored to people living with chronic conditions.


To reach their objectives the CCMT has developed 2 main projects to support the dissemination  of the integrated care model, and its related research and education initiatives for people involved in chronic care in the whole territory. 



  • The ProPCC project was developed to create and evaluate an innovative model of integrated care provision tailored to  high-need people living with complex chronic and advanced conditions. The Metropolitan North Community-based Integrated Care Programme for People with Complex Chronic Conditions (Programa ProPCC MetroNord ICS) was set up in 2018 by collecting data about experiences within the health system and identifying priorities of patients and caregivers. These were combined with evidence-based recommendations from local healthcare and social care professionals.


  • The ProFràgil project was developed to implement integrated care strategies for the care of older adults living with frailty, with the aim of encouraging  healthy ageing initiatives, maximising functional status and minimising complications related to the progression of frailty status. The project will have two main impacts:


                - In the community: it is focused on early identification of frailty in older community-dwelling adults to reduce the impact of their condition by preventing the onset of disability. Our group participated                      in the Aptitude project (financed by the Interreg-Pontecfa programme from the European Union), by disseminating  the WHO-ICOPE strategy and the AMICOPE tool in the town of Badalona


- In the hospital, new resources linked to the Germans Trias Geriatrics Department have been developed to impact on the frailty pathway in two stages: a) Before a stressful event, in order to prevent complications: classifying patients based on frailty indexes, supporting decision-making, optimising intensity of treatments and optimising individuals (prehabilitation). b) After the stressful event (hospital admission, surgery, medical treatments, etc): early management to minimise complications related to frailty during hospitalisation and aiming for an early discharge back into the community



Links on the ProPCC Programme can be found here:



Link to the frailty initiatives in our territory can be found here: