Publication:
A Methodological Approach for Implementing an Integrated Multimorbidity Care Model: Results from the Pre-Implementation Stage of Joint Action CHRODIS-PLUS.

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2019-11-06

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Palmer, Katie
Carfì, Angelo
Angioletti, Carmen
Di Paola, Antonella
Navickas, Rokas
Dambrauskas, Laimis
Jureviciene, Elena
João Forjaz, Maria
Rodriguez-Blazquez, Carmen
Prados-Torres, Alexandra

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Abstract

Patients with multimorbidity (defined as the co-occurrence of multiple chronic diseases) frequently experience fragmented care, which increases the risk of negative outcomes. A recently proposed Integrated Multimorbidity Care Model aims to overcome many issues related to fragmented care. In the context of Joint Action CHRODIS-PLUS, an implementation methodology was developed for the care model, which is being piloted in five sites. We aim to (1) explain the methodology used to implement the care model and (2) describe how the pilot sites have adapted and applied the proposed methodology. The model is being implemented in Spain (Andalusia and Aragon), Lithuania (Vilnius and Kaunas), and Italy (Rome). Local implementation working groups at each site adapted the model to local needs, goals, and resources using the same methodological steps: (1) Scope analysis; (2) situation analysis-"strengths, weaknesses, opportunities, threats" (SWOT) analysis; (3) development and improvement of implementation methodology; and (4) final development of an action plan. This common implementation strategy shows how care models can be adapted according to local and regional specificities. Analysis of the common key outcome indicators at the post-implementation phase will help to demonstrate the clinical effectiveness, as well as highlight any difficulties in adapting a common Integrated Multimorbidity Care Model in different countries and clinical settings.

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Adult
Aged
Aged, 80 and over
Chronic disease
Delivery of health care, integrated
Female
Humans
Lithuania
Male
Middle aged
Multimorbidity
Patient care planning
Pilot Projects
Program development
Rome
Spain

DeCS Terms

Anciano
Desarrollo de programa
Enfermedad Crónica
España
Multimorbilidad
Planificación de atención al paciente
Prestación integrada de atención de salud

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Keywords

Europe, care manager, care model, chronic disease, comprehensive assessment, individualized care plans, integrated care, multimorbidity, non-communicable diseases

Citation

Palmer K, Carfì A, Angioletti C, Di Paola A, Navickas R, Dambrauskas L, et al. A Methodological Approach for Implementing an Integrated Multimorbidity Care Model: Results from the Pre-Implementation Stage of Joint Action CHRODIS-PLUS. Int J Environ Res Public Health. 2019 Dec 11;16(24):5044