Inclusive Life Projects for people with Serious Mental Disorder and/or addictions

Abstract Project “Inclusive Life Projects” offers comprehensive and community care to people with SMD/A within projects of autonomous living, which provide a concrete and real response to their needs, with the ultimate objective of avoiding the risk of institutionalization. Currently, 26 actions have been designed and are being implemented within JA ImpleMENTAL pilot in five municipalities in the Region of Murcia: Caravaca, Cartagena, Lorca. Molina de Segura and Yecla with a participation of 50 people with SMD/A. The following elements are selected from the Belgian good practice: • Creation of local intersectoral networks promoting person-centered care process; • Personalization of care through the Individualized Care Plan, responding to the needs, and desires of people with SMI/A, activating the appropriate support; • Professional case manager. It generates the well-being of people on an empathy and trust basis and articulates coordination so that the agreed Plan can be developed as planned. A strategic and support coordination tool for action and facilitation of institutional support, the Social and Health Coordination Protocol for people with SMI/A, has been developed. The protocol facilitates the creation of coordination structures, among them the Socio-Health Coordination Base Teams stand out, teams made up of professionals from the different agents involved, multi-professional and intersectoral, (Mental Health, Primary Health Care, Social Services, Social Initiative) taking into account the needs of the person. It also serves to share information, detect training needs, influence resources, etc. PETRA, a computer platform, has been developed for sharing information between the systems involved, especially the health system and the social services system, both primary care, hospital care and specialized care. It allows the exchange of information, in real time, between professionals, the planning of actions, and the design of indicators and control and evaluation processes.