Towards more effective, efficient, and person-centered care for patients with chronic conditions in Spain through the CARABELA initiative

INTRODUCTION: Chronic multimorbidity, aging and care fragmentation challenge health systems. In Spain, strengthening coordination between primary and hospital care may support more effective chronic disease management. OBJECTIVE: The CARABELA PC-HC initiative proposes an integrated, patient-centered approach to strengthen chronic care continuity across levels. METHODS: This cross-sectional analysis included five CARABELA initiatives (from May 2019 to October 2024) supported by ten Spanish scientific societies and AstraZeneca. Centers were selected for territorial representativeness, structural diversity, and population size. The CARABELA methodology included: design of the ideal care process based on clinical guidelines and real-world practice; identification of improvement areas (IAs) and solutions; validation of proposals and quality indicators (QIs) through a national Delphi consensus; and development of a Whitebook incorporating patient input and dissemination via the CARABELA Playbook platform. RESULTS: Chronic care delivery was mapped across 124 Spanish health areas, covering 1337 centers and 10,696 professionals. Globally, 82 IAs, 282 solutions, and 121 QIs were identified. Prioritized IAs included poor care continuity, lack of shared protocols, limited patient education, and uneven digital integration. Professionals emphasized coordination, training, and clinical protocols; patients prioritized autonomy, information, and emotional support. A core set of 54 cross-cutting solutions (including shared electronic health records and multidisciplinary pathways) and 46 transversal indicators was defined to guide implementation and evaluation. CONCLUSIONS: CARABELA PC-HC provides a scalable framework to optimize chronic care integration. By aligning processes and patient-centered professional collaboration, it supports coordinated care models that enhance clinical outcomes, efficiency and equity, with potential applicability to other health systems.