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 ...

Towards an Integrated Care Organisation from a CEO Perspective

Many experimental projects towards Person-Centred Care (PCC) are successful in the early stages, but founder when the attempt is made to scale them up to encompass the whole organisation. This case study therefore focusses on one manager’s attempts to extend the successes of a preliminary project ‘Etxean Ondo’ that aimed to provide adequate support for the elderly living at home or in nursing homes, as well as for their families and care professionals. Through in-depth interviews with stakeholders, this qualitative study, based on Grounded Theory, sets out to analyse which behaviours, attitudes and values on the part of management appeared to favour full-integration of PCC in this wider context. Analysis of the data gathered allowed the researcher to generate an experimental case model which suggests how the extrinsic, intrinsic and transcendent motivation of stakeholders can be aligned with the goals of upper management to promote full-integration of PCC in ...