HomeResearchProjectsETXEAN ONDO PROJECT Home environment. Person-Centred Care Model

ETXEAN ONDO PROJECT Home environment. Person-Centred Care Model


Etxean Ondo is a pilot project that aims to implement and validate the comprehensive person-centred care model for people who are in situations of frailty or dependency, and who live in their own homes.

It revolves around a set of core principles, among which are personal autonomy and the continuity of care, which is in line with the scientific evidence produced and international (Convention on the Rights of Persons with Disabilities, 2006) and state (Law on the Promotion of Personal Autonomy and Care for Dependent Persons, 2006 -LAPAD-) standards.

The model, on the other hand, fits and is fully consistent with that described in the Law 12/2008 of Social Services of the Basque Country, as well as in the corresponding part, with the Strategy to meet the challenge of chronicity in the Basque Country and the Framework document for geriatric care guidelines.

Therefore, the project pivots on coordination between levels of Social Services (primary and secondary) and other Sectors (housing, education, citizen participation ...). Special emphasis has been given to coordination with the Health System, to validate that the coordinated geriatric care obtained satisfactory results in terms of efficiency in public systems and offers the users access to a fluid, comprehensive and continuous path with services of a different nature.

To achieve progress in personalised and comprehensive care, in home care experiences, it must be considered that a key figure of professional reference mentioned Law 12/2008 determines how each person or family user is assigned. These professionals work on this project, following the case management methodology in order to ensure consistency of care itineraries and coordination of interventions.



  • That elderly people and people with disabilities in need of support and care and their family caregivers receive it in a comprehensive, coordinated and continuous manner, and in the best conditions for their wellbeing and quality of life, ensuring greater independence and personal autonomy.
  • That through these pilot projects, using new methodologies (case management, comprehensive and person-centred care), knowledge about the effectiveness and efficiency of the applied model is generated.


As especially high-valued elements with regard to the intervention methodology and the coordination between sectors, it should be noted that the application of the case management method, which is done by the municipal social workers (professional references), who see this approach as a qualitative leap that they value highly both in terms of improving their professional qualifications, and, especially, for the high efficiency of their intervention with this methodology. As for the geriatric health coordination between case managers and nurses of health teams in Health Centres, the assessment is of great mutual enrichment and high effectiveness and efficiency in coordinated interventions.

The new element we assess is the change of the concept in geriatric care to organise it according to the needs and decisions of the person (Comprehensive Person-Centred Care Model).

At the organisational level, the element that we identify as the most transformative advance in geriatric care coordination is the implementation of the position of Case Manager (municipal social worker in charge of coordinating basic social services and primary health care).

At the level of care, we highlight the availability of several tools to perform a comprehensive needs assessment of the person and the caregiver; the Care and Life Plan that customises services to be received and that facilitates the participation of the person in the intervention process.

Based on experience, up to now and without having finished the experience, a number of recommendations are laid out that were derived from the results of Etxean Ondo application, facing the future direction of care services, which is considered desirable to incorporate into the planning and management of them:

  1. The assessment of cases of people in a situation of frailty or dependency must be comprehensive and, therefore, consider not only the person in their bio-psycho-social dimensions (physical ability, cognitive, emotional state, health, social network , loneliness, strengths and preserved abilities...), but rather their primary caretaker to avoid overloads and adverse effects to their health, and take the accessibility features in the home and the convenience of using support products into account. It is recommended, in this regard, that in assessments of the situation of dependency, that this is added to the dimensions mentioned. That way the diagnosis of the case prior to the intervention can be facilitated. Also, incorporating the Person's Life History as a key element of personalisation.
  2. Home care should be the support in which a set of local services (meals, podiatry, physiotherapy, hairdresser, escort, door to door transport...) can be integrated, as well as those related to household accessibility and promoting personal autonomy. All these services are especially valued by users, who consider them very useful for their quality of life, which is what should be taken into account for a budget increase in this area.

    Moreover, to perform this integration, the SAD's field of action should be expanded, further developing community intervention and promoting coordination between the different services, professionals and resources, be them competition for base social services, the Council or the Government, or relying on suppliers or private entities.
  3. Telephone assistance, in its basic and advanced modalities, should be articulated with the care of the SAD to exploit synergies and mutual benefits. To do so, they would have to perfectly understand the benefits and applications that are appropriate to state and include in personalised care plans, as appropriate. This service, in both its basic and advanced form, has been highly valued by users and also has a potential for future development, which should be taken into account.
  4. The SAD will continue to play a key role in the cases of many people who, without access to assistance derived from the LAPAD, do require home care precisely to prevent the onset or worsening of avoidable dependencies. Due to this, it is highly advisable not to lose sight of this function of the SAD, thus generating wellbeing produced by the prevention or avoidance of risks which can lead to premature and severe situations of dependency and, therefore, demanding intense and expensive care.
  5. In supporting people who opt for financial assistance to organise their care independently, the SAD can perform a very effective action at a low cost, such as the generalisation of the programme, Accompanying all who have financial assistance. The Etxean Ondo experience is showing that this service is very useful and has been evaluated so far, as being very satisfying for people in situations of dependency and, in particular, to caretakers. The dual function of support for families that this programme provides, counselling and on-site training (in the home) and respite to rest from care by a low intensity SAD is complemented by another key objective, as is supervision and control of the quality of care provided by the family or by the personal assistant hired and the suitability of these caregivers.
  6. It is highly recommended to proceed with the experiences of care coordination, integrating the action of health services with that of social services, at least in cases of population stratification under the Chronicity Strategy that matches people in situations of dependency. The assessment of people who have had the opportunity to receive this coordinated care in the sample of Etxean Ondo Project was very high, as it was considered a satisfactory experience among professionals (social workers and nurses) who participated in the interventions. Looking ahead, the establishment of agreements such as those that have been initiated in some municipalities could ensure stability and the progressive generalization of this coordinated action.
  7. Encourage the SAD technicians to acquire enough training to carry out the functions of planners and case managers with a leading role in monitoring the quality of care and in the support and training of caregivers in the family environment.
  8. Encourage the diversification of "categories" of personal assistants depending on the type of tasks to be performed in the homes, with the consequent cost diversification. When it comes to cases where suitable support is carrying out domestic tasks, there should be financial assistance when there are insufficient family resources to hire a domestic employee.
  9. Explore the most appropriate ways for people hired by the family to acquire basic training in caring for people in vulnerable situations or dependence, also promoting the regularisation of the employment status of those who have not yet done so.
  10. Within the vision of community intervention, which is recommended for increasing social services, personalised care plans should take into account the importance of participation and social inclusion of people who are in situations of frailty or dependency. Also, in municipalities, greater social and community integration of the elderly and people with disabilities should be encouraged.
  11. Spread the concepts of universal design and accessibility to the entire population, as has been the goal in the municipalities where it has been in operation since Etxean Ondo, it should be intensified in municipalities and in other territories.
  12. It is very convenient to incorporate case management methodology into the intervention of social services and geriatric care, at least with regard to the profiles that require long and complex care. Learning and good results in the development of the Etxean Ondo Project should be exploited to apply them in the conceptualisation of interventions, the definition of the roles and functions of the professionals who could develop this method, and with regard to the training prior to joining.
  13. Looking ahead and as could be observed over the course of the experience gained with the implementation of the Etxean Ondo project, a simplification of conceptualizations and systems of access to aid and services is highly recommended, promoting its flexibility and advancing in a structure of the systems to make the processes more agile and transverse.


In its design and implementation, the following Public Administrations and other entities from the Sector are involved:

  • Basque Government. Department of Employment and Social Policies
  • Territorial Directorates of Health of Gipuzkoa and Álava.
  • Municipalities of San Sebastián, Tolosa, Oiartzun, Zarautz and Irún (Guipúzcoa)
  • Ten municipalities in the Cuadrilla de Añana (Álava)
  • Regional Council of Álava.
  • Health centres from the corresponding municipalities.
  • Home Care Service Providers and other local services
  • Fundación Pilares for Personal Autonomy, who serves as the technical director.

As technical support and overall coordination, as well as in each municipality participating in the project, the MATIA Institute participates through a collaboration agreement with the Basque Government.