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Identification and analysis of integrated care programmes (N=119)
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Multimordibity: Setting a framework from practices
Mieke RijkenNIVEL, NLGraziano OnderAIFA, IT
3rd Stakeholders Forum JA-CHRODIS
4th February 2016
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WP6 task 2:Review existing care (pathway) approaches for multimorbidity patients
Activities:1. Identification and analysis of integrated care programmes targeting patients with multimorbidity in European countries
2. Review the evidence on the effectiveness of integrated care programs targeting patients with multimorbidity
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Identification and analysis of integrated care programmes (N=119)
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Examples
POTKU, Finland Clinic for Multimorbidity and Polypharmacy, Denmark
Strategy for Chronic Care Valencia Region, Spain
Main aim: Improve patient-centredness
Substitution, support primary care
Improve delivery of integrated care
Target group:
Chronic patients Chronic patients with more complex needs
Patients with ‘highly complex needs’
Based in: Primary care Diagnostic clinic in hospital Primary care + hospital care
Care model:
PC doctor/nurse teams, individual care plan
teams of specialists/others, ‘one day’-service, treatment plan for care by PC doctor
Community nurse case manager + hospital nurse case manager, joint monitoring
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Results
Quality of care Patient outcomes Utilization / costsPOTKU, Finland Patients with individual care
plan more positive (PACIC). Care providers experience improved quality (ACIC).
Use of primary care decreased (2012-2014), except phone calls to nurses.
Clinic for Multimorbidity and Polypharmacy, Denmark
Improved quality and coordination of care according to care providers involved
“The multimorbidity clinic results in a more efficient use of hospital resources.”
Strategy for Chronic Care Valencia Region, Spain
Between 2011 and 2013 decrease of older people with polypharmacy of 34 300 (-10%).
In 2012-2014, > 200 000 patients with polypharmacy reviewed and 100 000 drug prescriptions changed, resulting in decrease of expenditures on drugs, from 19.5 million Euros in 2012 to 7.3 million in 2014.
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Some conclusions
• Variety in models and approaches• Role of nurses• Few with specific multimorbidity perspective
• Not very well evaluated (yet)• Systematic review (2nd activity): inconclusive results
Lack of evidence regarding effectiveness and effective components of care programs/practices
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How to define a MM care model?
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Problems
• Lack of evidence• Poor standardization• Heterogeneity of practices (Mixed interventions)
Building consensus among experts
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Approach
1. Identification of components of practices (interventions) and classification based on the CCM
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Components
Delivery system design– Comprehensive assessment– Multidisciplinary team– Individualized care plans– Case manager
Decision support– Implementation of EBM– Team training – Consultation system
Self management– Tailor Self-management – Health literacy– Patient education– Family education– Approaches self-management– Patients in decision making – Training medical devices
Community resources– Access community resources – Involvement of social network– Psychosocial support
Clinical information system– Electronic patients records– Exchange patients infos– Uniform coding– Computerized systems
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Approach
1. Identification of components of practices (interventions) and classification based on the CCM
2. Expert opinion
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Experts
Joao Forjaz Mieke RijekenElena Jureviciene Ulrike Rothe Alessandra Marengoni Laurène Souchet Christian Muth* Vontetsianos TheodoreRokas Navickas Josè Valderas*Graziano Onder Jelka Zaletel Alexandra Prados-Torres
*External experts
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Experts meeting - Results
16 components selectedFor each component:
– Description and aims– Key characteristics– Relevance to multimorbidity patients
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Experts meeting - Results
Delivery system design– Comprehensive assessment– Coordinated team– Individualized care plans– Case manager
Decision support– Implementation of EBM– Team training – Consultation system
Self management– Tailor Self-management – Options for self management– Shared decision making
Community resources– Access community resources – Involvement of social network
Clinical information system– Electronic patients records– Exchange patients infos– Uniform coding– Patient operated technology
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Conclusion
• This care model needs to be assessed and validated in a real life setting to determine specifically how and to what extent multimorbidity patients will benefit from it;
• Specific research questions of interest may focus on how this care model can be applied across different settings in various European countries;
• Costs and benefits to the patients and families, and practical application of the care model within care and medical setting should all be considered
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The Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS)** This presentation arises from the Joint Action addressing chronic diseases and healthy ageing across the life cycle (JA-CHRODIS), which has received funding from the European Union, under the framework of the Health Programme (2008-2013). Sole responsibility lies with the author and the Consumers, Health, Agriculture and Food Executive Agency is not responsible for any use that may be made of in the information contained therein.
