[Continuity of care, innovation and redefinition of professional roles in the healthcare of chronically and terminally ill patients. SESPAS report 2012].

Continuity of care is essential to address the multiple needs of the chronically and terminally ill. To achieve this aim, the organizational barriers of the different levels of care must be overcome by establishing appropriate coordination mechanisms. Interest in finding effective solutions to the problems that threaten continuity of care is increasing, favoring the continued development of professional and institutional strategies to improve coordination. The present article explores some of the proposals to improve the coordination of care in primary care settings, from the point of view of nursing, social work and palliative care. Due to the increase in patients with chronic and complex needs and multimorbidity, the number and quality of home visits should be increased. The effectiveness of home care depends on the regularity of follow-up and the stability of the healthcare programs, rather than on the service responsible for monitoring the patient or the professional responsible for home visits.