Managing multimorbidity: profiles of integrated care approaches targeting people with multiple chronic conditions in Europe

In response to the growing populations of people with multiple chronic deseases, new models of care are currently being developed in European countries to better meet the needs of these people. This paper aims to describe the occurrence and characteristics of various types of ntegrated care practices in European countries that target people with multimorbidity.

Community Care for People with Complex Care Needs: Bridging the Gap between Health and Social Care

Introduction: A growing number of people are living with complex care needs characterized by multimorbidity, mental health challenges and social deprivation. Required is the integration of health and social care, beyond traditional health care services to address social determinants. This study investigates key care components to support complex patients and their families in the community.

Methods: Expert panel focus groups with 24 care providers, working in health and social care sectors across Toronto, Ontario, Canada were conducted. Patient vignettes illustrating significant health and social care needs were presented to participants. The vignettes prompted discussions on i) how best to meet complex care needs in the community and ii) the barriers to delivering care to this population.

Results: Categories to support care needs of complex patients and their families included i) relationships as the foundation for care, ii) desired processes and structures of care, and iii) barriers and workarounds for desired ...

Patient-centred care for multimorbidity: an end in itself?

Multimorbidity, which is defined as living with two or more chronic health problems, is a major and growing problem, especially in societies with ageing populations and substantial socioeconomic disparities. It is associated with reduced quality of life, impaired functional status, poor physical and mental health, and increased mortality

Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach

The management of people with multiple chronic conditions challenges health-care systems designed around single conditions. There is international consensus that care for multimorbidity should be patient-centred, focus on quality of life, and promote self-management towards agreed goals. However, there is little evidence about the effectiveness of this approach. The article´s hypothesis was that the patient-centred, so-called 3D approach (based on dimensions of health, depression, and drugs) for patients with multimorbidity would improve their health-related quality of life, which is the ultimate aim of the 3D intervention.

Patient centred care for multimorbidity improves patient experience, but quality of life is unchanged

The UK has an ageing population. A 2018 study of multimorbidity in England found that 54% of people over 65 had multimorbidity in 2015. This is expected to rise to 68% by 2035, with 17% of people over 65 expected to have four or more conditions. National guidelines tend to focus on single conditions. People with multimorbidity may have their conditions managed individually without due consideration of the overall burden of their diseases and treatments. Recognition of this prompted the National Institute for Health and Care Excellence (NICE) and other international organisations to develop guidelines on managing multimorbidity. These focus on regular comprehensive review of the person’s health and circumstances. This trial assessed a care model that incorporated all strategies recommended by guidelines.

What is Important to Older People with Multimorbidity and Their Caregivers? Identifying Attributes of Person Centered Care from the User Perspective

Health systems are striving to design and deliver care that is ‘person centered’—aligned with the needs and preferences of those receiving it; however, it is unclear what older people and their caregivers value in their care. This paper captures attributes of care that are important to older people and their caregivers.

From protocolized to person-centered chronic care in general practice: study protocol of an action-based research project (COPILOT)

The management of people with multiple chronic diseases challenges health care systems designed around single disease. Patients with multimorbidity often receive highly fragmented care that may lead to inefficient, ineffective and potentially harmful treatments and neglect of essential health needs. A more comprehensive, person-centered approach is advocated for persons with multiple morbidities. However, examples on how to provide more person-centered care and evidence of its impact are scarce.
The aim of this study was to develop a proactive person-centered care approach for persons with (multiple) chronic diseases in general practice, and to explore the impact on ‘Quadruple aims’: experiences of patients and professionals, patient outcomes and costs of resources use.

The “Patient-centered coordination by a care team” questionnaire achieves satisfactory validity and reliability

Increasing prevalence of chronic conditions and multimorbidity challenges health care systems and calls for patient-centered coordination of care. Implementation and evaluation of health policies focusing on the development of patient-centered coordination of care needs valid instruments measuring this dimension of care. The aim of this validation study was to assess the psychometric properties of the French version of the 14-item Patient-Centered Coordination by a Care Team (PCCCT) questionnaire in a primary care setting. 

A 10 Step Framework to Implement Integrated Care for Older Persons

An aging population, whose multi-morbidities and risk of frailty increase with age results in significant health and social care consumption. Increasing complexity amplifies fragmentation of care and results in sub optimal care outcomes. There is growing evidence base supporting effective service responses for older persons. These typically include multidisciplinary, community based teams providing services in or near to the older person’s home (the ‘what’). However, examples of systemic implementation are confined to smaller regions notably in Catalonia (Spain), Scotland and Singapore. This reflects the fact that the implementation of integrated care is problematic at scale. The need to attend to methods that support high autonomy professionals tasked with local implementation (the ‘who’) is a neglected area. This paper proposes a framework to implementing integrated care for older persons. In addition, it offers some initial empirical evidence that this approach has utility among managers and clinicians. In doing so seeks ...

Evaluation of integrated care services in Catalonia: population-based and service-based real-life deployment protocols.

Comprehensive assessment of integrated care deployment constitutes a major challenge to ensure quality, sustainability and transferability of both healthcare policies and services in the transition toward a coordinated service delivery scenario. To this end, the manuscript articulates four different protocols aiming at assessing large-scale implementation of integrated care, which are being developed within the umbrella of the regional project Nextcare (2016-2019), undertaken to foster innovation in technologically-supported services for chronic multimorbid patients in Catalonia (ES) (7.5 M inhabitants). Whereas one of the assessment protocols is designed to evaluate population-based deployment of care coordination at regional level during the period 2011-2017, the other three are service-based protocols addressing: i) Home hospitalization; ii) Prehabilitation for major surgery; and, iii) Community-based interventions for frail elderly chronic patients. All three services have demonstrated efficacy and potential for health value generation.

Should community pharmacy be 'linked'? The perceptions of including community pharmacy in an integrated care model in Ontario, Canada

Integrated care models are becoming more frequent in various health systems to provide quality coordinated care, with the aim of improving patient outcomes and costs. Many patients under an integrated care model present with complex health and social needs requiring more sophisticated care coordination. 

Implementing integrated care for multi-morbidity: analysis of experiences in 17 European programmes

Many countries are experimenting with new models of care provision and numerous integrated care programmes have been established internationally. However, little information is available on how to implement integrated care. The aim of this study was to provide more in-depth insights in the implementation of integrated care for developers and managers of integrated care programmes, policy makers, health insurers, and researchers.

Whole-person care in general practice: The nature of whole-person care.

Whole-person care (WPC) is a core value of general practice and is particularly relevant with increasing population multimorbidity. However, WPC has lacked consensus definition, and some argue that it is not consistently practised. The aim of this study was to determine Australian general practitioners' (GPs') understanding of WPC and factors affecting its provision. This article (the first in a three-part series) describes GPs' understanding of WPC.

Sharing responsibility: municipal health professionals’ approaches to goal setting with older patients with multi-morbidity – a grounded theory study

Recent health policy promoting integrated care emphasizes to increase patients’ health, experience of quality of care and reduce care utilization. Thus, health service delivery should be co-produced by health professionals and individual patients with multiple diseases and complex needs. Collaborative goal setting is a new procedure for older patients with multi-morbidity. The aim is to explore municipal health professionals’ experiences of collaborative goal setting with patients with multi-morbidity aged 80 and above.

Integrated Care Programs for People with Multimorbidity in European Countries: eHealth Adoption in Health Systems

eHealth applications have the potential to provide new integrated care services to patients with multimorbidity (MM), also supporting multidisciplinary care. The aim of this paper is to explore how widely eHealth tools have been currently adopted in integrated care programs for (older) people with MM in European countries, including benefits and barriers concerning their adoption, according to some basic health system characteristics.

Impact Assessment of an Innovative Integrated Care Model for Older Complex Patients with Multimorbidity: The CareWell Project

In aging populations, multimorbidity (two or more chronic diseases in the same person) is very common. Patients with multimorbidity have complex health and social needs, are at risk of being admitted to the hospital or residential care home and require a wide range of interventions.

To satisfy the needs of these patients and their families, new innovative integrated care models are needed. To be effective, they should have primary care as the cornerstone of care, effective integration between care levels, empower patient and carers/families, and should be patient-centered. The use of information and communication technology (ICT) platforms could facilitate and improve communication promoting patient empowerment and home support. This innovative interoperability should increase effectiveness, efficiency, and equity.

The aim of the CareWell project was to implement and to assess the effectiveness of an integrated care program based on the coordination between health providers, home-based care, and patient empowerment, supported ...

Impact of the CareWell integrated care model for older patients with multimorbidity: a quasi-experimental controlled study in the Basque Country

Older patients with multimorbidity have complex health and social care needs, associated with elevated use of health care resources. The CareWell program for older patients with multimorbidity, is based on the coordination between health providers, home-based care and patient empowerment, supported by information and communication technology tools. The implementation of CareWell integrated care model changed the profile of health resource utilization, strengthening the key role of primary care and reducing the number of emergency visits and hospitalizations

Telemonitoring and continuity of care for older subjects: comparing experience an identifying common solutions

The COVID19 pandemic highlighted some structural – organizational and cultural – limitations of our dominant model of (health)care. One of these is the need to identify and adopt newer instruments for the continuity of care for the large number of patients with chronic disease who live in low-density population areas  (200 million or 27% of EU population) and experience inequality to access (health)care because of the distance between community and healthcare structures. Notably, the onset of multimorbidity occurs 10–15 years earlier in people living in the most deprived areas compared with the most a?uent.

The Workshop aims at facilitating knowledge acquisition (including existing Projects and adopted solutions) and at fostering collaboration and standardization of best practice, including health literacy and patients and caregivers empowerment, in order to impact on the adoption of innovative digital solutions able to boost people's health and quality of life and enable more ...

Integrating patient complexity into health policy: a conceptual framework

Clinicians across all health professions increasingly strive to add value to the care they deliver through the application of the central tenets of people-centred care (PCC), namely the ‘right care’, in the ‘right place’, at the ‘right time’ and ‘tailored to the needs of communities’.

This ideal is being hampered by a lack of a structured, evidence-based means to formulate policy and value the commissioning of services in an environment of increasing appreciation for the complex health needs of communities. This creates significant challenges for policy makers, commissioners and providers of health services. Communities face a complex intersection of challenges when engaging with healthcare. Increasingly, complexity is gaining prominence as a significant factor in the delivery of PCC.

Based on the World Health Organization (WHO) components of health policy, this paper proposes a policy framework that enables policy makers, commissioners and providers of health care to integrate a model of ...

TeNDER successfully completes pre-piloting phase. An Integrated Health Care model for patients with neurodegenerative and cardiovascular conditions

Prevalence of non-communicable chronic conditions, multimorbidity and its correlates among older adults in rural Nepal: a cross-sectional study

The population of older adults is increasing globally and is projected to increase to over 1.5 billion by 2050. A similar demographic transition is occurring in Nepal. While we celebrate longevity, health and quality of life are two crucial agendas for the older population. Older adults have a higher prevalence of non-communicable chronic conditions, and with longevity, the likelihood of experiencing more than one non-communicable chronic condition also increases.

This study’s objectives were to estimate the prevalence of major non-communicable conditions and multimorbidity among older adults in rural Nepal and examine the associated socioeconomic and behavioural risk factors.

Clustering Complex Chronic Patients: A Cross-Sectional Community Study From the General Practitioner’s Perspective

Games of uncertainty: the participation of older patients with multimorbidity in care planning meetings – a qualitative study

Active patients lie at the heart of integrated care. Although interventions to increase the participation of older patients in care planning are being implemented in several countries, there is a lack of knowledge about the interactions involved and how they are experienced by older patients with multimorbidity. We explore this issue in the context of care-planning meetings within Norwegian municipal health services.

Treatment outcomes among adults with HIV/non-communicable disease multimorbidity attending integrated care clubs in Cape Town, South Africa

The growing burden of the HIV and non-communicable disease (NCD) syndemic in Sub- Saharan Africa has necessitated introduction of integrated models of care in order to leverage existing HIV care infrastructure for NCDs.

“To be seen” – older adults and their relatives’ care experiences given by a geriatric mobile team (GerMoT)

The proportion of older people in the population has increased globally and has thus become a challenge in health and social care. There is good evidence that care based on comprehensive geriatric assessment (CGA) is superior to the usual care found in acute hospital settings; however, the evidence is scarcer in community-dwelling older people.The participants of this study found the care easily accessible, and that contacts could be taken according to needs by health care professionals who knew them. This is in accordance with person-centred care as recommended by the World Health Organisation (WHO) for older people in need of integrated care.

Designing a person-centred integrated care programme for people with complex chronic conditions: a case study from Catalonia

The prevalence of people with complex chronic conditions is increasing. This population’s high social and health needs require person-centred integrated approaches to care. We developed an evidence-based integrated care programme tailored to high-need patients combining input from patients, caregivers, and healthcare and social care professionals. Patients’ and caregivers’ main priorities were to ensure (a) comprehension of information provided by healthcare professionals; (b) coordination between patients, caregivers, and professionals; (c) access to social services; (d) support to caregivers in managing situations; (e) perceived support throughout the healthcare process; (f) home care, when available; and (d) a patient-centred approach

A Digital Health Platform for Integrated and Proactive Patient-Centered Multimorbidity Self-management and Care (ProACT):Protocol for an Action Research Proof-of-Concept Trial

Multimorbidity is defined as the presence of two or more chronic diseases and associated comorbidities. There is a need to improve best practices around the provision of well-coordinated, person-centered care for persons with multimorbidities. Present health systems across the European Union (EU) focus on supporting a single-disease framework of care; the primary challenge is to create a patient-centric, integrated care ecosystem to understand and manage multimorbidity. ProACT is a large-scale project funded by the European Commission under the Horizon 2020 programme, that involved the design, development, and evaluation of a digital health platform to improve and advance home-based integrated care, and supported self-management, for older adults (aged ≥65 years) living with multimorbidity.

Systematic review of patient-engagement interventions: potentials for enhancing person-centred care for older patients with multimorbidity

Person-centred care based on systematic and comprehensive patient-engagement is gaining momentum across healthcare systems. Providing care that is responsive to the needs, values and priorities of each patient is important for patients, relatives and providers alike, not least for the growing population of older patients living with multi-morbidity and associated complex care trajectories.

Integrated Care for Multimorbidity Population in Asian Countries: A Scoping Review

The complex needs of patients with multiple chronic diseases call for integrated care (IC). This scoping review examines several published Asian IC programmes and their relevant components and elements in managing multimorbidity patients. In the IC programmes for patients with multimorbidity in Asia, service delivery, leadership, and workforce were most frequently mentioned, while the financing component was least mentioned.

Exploring Intra and Interorganizational Integration Efforts Involving the Primary Care Sector – A Case Study from Ontario

he primary care sector is uniquely positioned to lead the coordination of providers and organizations across health and social care sectors. This study explores whether intraorganizational (professional) integration within a primary care team might be related to interorganizational integration between primary care and other community partners involved in caring for complex patients.

General practitioners' perceptions of distributed leadership in providing integrated care for elderly chronic multi-morbid patients: a qualitative study

Distributed Leadership (DL) has been suggested as being helpful when different health care professionals and patients need to work together across professional and organizational boundaries to provide integrated care (IC). This study explores whether General Practitioners (GPs) adopt leadership actions that transcend organizational boundaries to provide IC for patients and discusses whether the GPs’ leadership actions in collaboration with patients and health care professionals contribute to DL.

A Systematic Review of Interventions that Use Multidisciplinary Team Meetings to Manage Multimorbidity in Primary Care

Multidisciplinary team (MDT) meetings could facilitate coordination of care for individuals living with multimorbidity, yet there is limited evidence on their effectiveness. We hence explored the common characteristics of MDT meetings in primary care and assessed the effectiveness of interventions that include such meetings, designed to improve outcomes for adults living with multimorbidity.

Development of a Person-Centred Integrated Care Approach for Chronic Disease Management in Dutch Primary Care: A Mixed-Method Study

To reduce the burden of chronic diseases on society and individuals, European countries implemented chronic Disease Management Programs (DMPs) that focus on the management of a single chronic disease. However, due to the fact that the scientific evidence that DMPs reduce the burden of chronic diseases is not convincing, patients with multimorbidity may receive overlapping or conflicting treatment advice, and a single disease approach may be conflicting with the core competencies of primary care. In addition, in the Netherlands, care is shifting from DMPs to person-centred integrated care (PC-IC) approaches.

Primary healthcare competencies needed in the management of person-centred integrated care for chronic illness and multimorbidity: Results of a scoping review

Chronic disease management is important in primary care. Disease management programmes focus primarily on the respective diseases. The occurrence of multimorbidity and social problems is addressed to a limited extent. Person-centred integrated care (PC-IC) is an alternative approach, putting the patient at the centre of care. This asks for additional competencies for healthcare professionals involved in the execution of PC-IC. In this scoping review we researched which competencies are necessary for healthcare professionals working in collaborative teams where the focus lies within the concept of PC-IC. We also explored how these competencies can be acquired.

Clinic for Multimorbidity: An Innovative Approach to Integrate General Practice and Specialized Health Care Services

Caring for patients with multimorbidity in general practice is increasing in amount and complexity. To integrate care for patients with multimorbidity and to support general practitioners (GPs), the Clinic for Multimorbidity (CM) was established in 2012 at Silkeborg Regional Hospital, Denmark. This case study aims to describe the CM and the patients seen in it.