Background Care models for advanced chronic patients present two key aspects: early identification and advanced care planning (ACP). In 2014, Catalonia arranged the ACP Model (ACPM), addressed to chronic patient’s complex needs, into a public health-social system (HSS).

Aims Describe the implementation process (IP) of an ACPM.

Methods A core group of professionals (n = 55) was convened to develop the ACPM with the co-participation of patients, caregivers, social agents and healthy persons. Inclusion criteria included: solid professional trajectory, equal representation as for territory and professional profile,

Four work levels were defined: conceptual document (CD) and implementation guide (IG) elaboration; training program (ITP) development; building-up of patients, professionals and healthy persons discussion groups (DG).

The CD and IG were written with the agreement of expert professionals in legislation, ethics, medical specialities, nursing, anthropology, social work and psychology. The ITP is being created, as a key aspect of the IP.

Results CD and IG have been published. Simultaneously, DGs are established so as to make the CD a work product of high quality. The ITP is currently being developed, based on CD and IG contents. These documents have been reviewed by around 100 professionals from the Catalan HSS.

The ITP contents focus on communication skills; legal and ethical aspects; patient and family needs.

Discussion ACP is a challenge for the model of care towards advanced chronic patients.

Conclusion The ACPM establishes the conceptual and need for systematic ACP implementation and promotes the training of the professionals daily taking care of such type of patients.