The aim of WP6 is to facilitate an improvement in the quality of chronic disease and multimorbidity management.
The Multimorbidity Care Model was developed in Joint Action CHRODIS (2014-2017). Within this current project, this model will be assessed in practice to prove its applicability. Consequently, use of this model will be validated throughout various European healthcare settings.
The primary focus is to field test the new Integrated Multimorbidity Care Model for people with multiple morbidities in primary and tertiary care hospitals in Lithuania, Italy and Spain (five pilot sites). Country-specific CHRODIS integrated care model versions will be developed as a result.
Who will benefit the most from this activity? Patients, primarily, as well as healthcare resources.
Timeline of Key Activities
- September 2017 – WP6 Kick-off Meeting
- August 2018 – Experts meeting to determine the preparatory phase and pilot strategy
- October 2018 – Report on the preparatory phase and scaling-up strategy
- Oct 2018 - Feb 2020 – Pilot implementation
- April 2020 – Pilot implementation and outcomes evaluation
- June 2020 – The development of country-specific CHRODIS integrated care model versions
Chrodis Plus for the benefit of European patients
Task leader: Catholic University of the Sacred Heard (UCSC) September 2017 – February 2018
Task 1.1 – Assessment of participating pilot sites
Leader: Catholic University of the Sacred Heart (UCSC). September 2017 – February 2018
A survey will be assembled to assess pilot sites participating in the implementation of the model. This survey will be developed in order to identify and assess the most relevant organisational characteristics of each facility.
Task 1.2 – Identification of patient risk stratification strategies
Leader: International Centre of Excellence in Chronicity Research (KRONIKGUNE). September 2017 – August 2018
Existing risk stratification strategies will be reviewed to identify and select the strategy/strategies that will be applied by the practices participating in the model’s implementation. Strategies adopted at the national or regional level will be reviewed through a survey of the partners participating in CHRODIS PLUS.
Task 1.3 – Defining an implementation strategy and tailoring of the intervention
Leader International Centre of Excellence in Chronicity Research (KRONIKGUNE) and Catholic University of Sacro Cuore (UCSC). February 2018 – August 2018
A meeting to discuss strategies for the implementation of the JA-CHRODIS integrated care model will be organised and will involve WP partners, the leaders of participating partners and external experts, as well as the leaders of the practices involved in the model’s implementation. The possible tools, instruments and outcomes that will be used to assess the success of the model’s implementation will be discussed and defined. Results may include patient-related outcomes, use of resources (i.e. hospitalisation) and process-oriented outcomes (i.e. quality and continuity of care as perceived by patients and professionals, sustainability, and organisational outcomes).
Task leader: Catholic University of Sacro Cuore (UCSC) and Vilnius University Hospital Santaros Klinikos (VULSK). September 2018 – February 2020
The JA-CHRODIS integrated care model will be implemented at participating practices in accordance with the previously defined methodology (see Task 1.3). The model will be implemented at five pilot sites in Italy, Lithuania and Spain. The following partners will implement the model in local or regional practices:
- Spain – Regional Ministry of Health of Andalusia (CSJA)
- Spain – Aragonese Institute for Health Sciences (IACS)
- Lithuania – Vilnius University Hospital Santaros Klinikos (VULSK)
- Lithuania – The Hospital of Lithuanian University of Health Sciences Kauno Klinikos (LSMU-KAUNO KLINIKOS)
- Italy – Catholic University of the Sacred Heart (UCSC)
This implementation task will be organised according to a six-month trial period, followed by a 12-month implementation period.
Task leader: Vilnius University Hospital Santaros Klinikos (VULSK) and Catholic University of Sacro Cuore (UCSC). September 2018 – February 2020
Participating practices will be visited by local partners involved in the WP at the beginning of the implementation phase and at least twice during the first year after the implementation phase has begun. Local partners will be involved in supporting implementation activities. Additional visits will be planned according to the needs of the individual practices.
Task leader: Aragonese Institute for Health Sciences (IACS) and the Institute of Health Carlos III (ISCIII). September 2018 – May 2020
Relevant outcomes that are identified during the preparatory phase, and agreed upon by the pilot sites identified in the experts’ meetings, will be assessed to determine the success of the model’s implementation (see Task 1.3).
In parallel with Task 3, and based on local experience and knowledge, participating partners will define the JA-CHRODIS integrated care model according to the specific characteristics of their local health care setting. Outcomes will be country specific versions of the model, which are fully adapted and tailored for local implementation.
Key Experts & Organisations
|Graziano Onder - Catholic University of the Sacred|
|Elena Jurevičienė – Vilnius University Hospital Santariskiu Klinikos, Lithuania (VULSK)|
“CHRODIS PLUS is an opportunity where joint European effort for identifying and redefining best practices is converted into actual practice across different healthcare setting with real results for communities. The work package on the implementation multimorbidity care model is like a bridge where multimorbidity related best practices are identified, checked and adjusted so that they can be implemented across a wide range of EU countries. We are excited and ready to steer our partners towards a commonly agreed upon goal."
GRAZIANO ONDER (Graziano.Onder@unicatt.it) & ELENA JUREVICIENE (Elena.Jureviciene@santa.lt)
lead the work package on
PILOT IMPLEMENTATION OF THE INTEGRATED CARE MODEL
CATHOLIC UNIVERSITY OF THE SACRED HEART, ITALY (Graziano Onder)
VILNIUS UNIVERSITY HOSPITAL (Elena.Jureviciene)
- WP6 leader Catholic University of Sacro Cuore (UCSC), Graziano Onder: email@example.com
- WP6 co-leader Vilnius University Hospital Santaros Klinikos (VULSK), Rokas Navickas, Elena Jureviciene: Rokas.Navickas@santa.lt
- Institute of Health Carlos III (ISCIII),
- International Centre of Excellence in Chronicity Research (KRONIKGUNE),
- European Patients Forum (EPF),
- National Institute of Health (ISS),
- The Hospital of Lithuanian University of Health Sciences Kauno Klinikos (LSMU-KAUNO KLINIKOS),
- National Institute of Public Health (NIJZ),
- Regional Ministry of Health of Andalusia (CSJA),
- Aragonese Institute for Health Sciences (IACS),
- National Institute of Geriatrics, Rheumatology and Rehabilitation (NIGRiR)
- Catholic University of the Sacred Heart (UCSC)
- Vilnius University Hospital Santaros Klinikos (VULSK)
- The Hospital of the Lithuanian University of Health Sciences Kauno Klinikos (LSMU-KAUNO KLINIKOS)
- Aragonese Institute for Health Sciences (IACS)
- Regional Ministry of Health of Andalusia (CSJA)
WP6 articles published in IJERPH
Link to the publication: https://www.mdpi.
This article is offered primarily to: doctors and health care managers
The Integrated Multimorbidity Care Model (IMCM), developed by the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS), proposes a set of 16 multidimensional components (i.e., recommendations) to improve the care of persons with multimorbidity in Europe. This study aimed at analyzing the potential applicability of the IMCM. We followed a qualitative approach that comprised two phases: (1) The design of a case study based on empirical clinical data, which consisted of a hypothetical woman with multimorbidity, type 2 diabetes mellitus, mental health, and associated social problems, and (2) the creation of a consensus group to gather the opinions of a multidisciplinary group of experts and consider the potential applicability of the IMCM to our case study. Experts described how care should be delivered to this patient according to each model component, suggested the use of specific rating scales and tools to assess her needs in a comprehensive and regular way, and pointed our crucial health and social resources to improve her care process. Experts also highlighted patient-centered, integrated and tailored care as one of the keystones of quality healthcare. Our results suggest that the IMCM is applicable in complex patients with multimorbidity.