The Portuguese National Network for Integrated Continuous Care (RNCCI) was introduced in 2007 as a joint initiative of the Ministry of Health and Social Solidarity to provide integrated and continuous care to dependent people. The network cuts across private, public, and nonprofit sectors to provide long-term, comprehensive and coordinated services, with a focus on community-based care.¹ The RNCCI is designed to provide patients and providers with continuous health monitoring information and support through the use of an online data management system (GestCare CCI) that records referrals, admissions, transitions, waiting time for admission, and the outcomes of needs assessments.² GestCare CCI supports smoother care transitions and simplifies tracking the patient across settings of care, promoting better information and management continuity between relevant care providers.³

The RNCCI is decentralized and organized into three levels of coordination at the national, regional, and local/provider level with quality indicators collected at each level through compulsory data submissions. To promote better case management, providers across the RNCCI network, including hospital discharge management teams, primary health care centers, local coordination teams, and regional and national coordination teams have access to the information in GestCare CCI.² Individuals within the RNCCI undergo a needs assessment with comprehensive care teams to create a personalized care plan. The care plan and results of the needs assessment are documented in GestCare CCI and coordinated across members within the care team to promote continuity of care across the range of providers involved in an individual’s care.²