Work package 6 members at the kick-off meeting of CHRODIS+ showing at WP leader


 MULTIMORBIDITY CARE MODEL

WORK PACKAGE 6

Objectives

The WP6 aims to promote fostering quality for management of chronic diseases and multimorbidity

The Multimorbidity Care Model was developed in Joint Action Chrodis (2014-2017). In this project this model will be assessed in practice, proving its applicability and its use will be validated across different European healthcare settings.

The main focus is on field-testing the new Integrated Multimorbidity Care Model for people with multi-morbidities in primary care and tertiary care hospitals in Lithuania, Italy and Spain. (5 pilot sites). As a result, country specific CHRODIS integrated care model versions will be elaborated.

Who will benefit most from this activity? Mostly the patients as well as resources in healthcare.

Timeline of Key Activities

TIMELINE OF KEY ACTIVITIES
  • September 2017 – WP6 Kick of Meeting
  • August 2018 – Experts meeting to define preparatory phase and strategy for pilot
  • August 2018 – Report on preparatory phase and scale up strategy
  • August 2019 – Pilot implementation
  • April 2020 – Pilot implementation and outcomes evaluation
  • June 2020 – Country specific CHRODIS integrated care model versions
TIMELINE CHART
  • August 2018 – Report on preparatory phase and scale up strategy
  • August 2020 – Pilot implementation
  • June 2020 – Country specific CHRODIS integrated care model versions

Main Tasks

TASK 1: PREPARATORY PHASE

Task leader: Catholic University of Sacro Cuore (UCSC) September 2017 – February  2018

Task 1.1 – Assessment of participating pilot sites

Leader: Catholic University of Sacro Cuore (UCSC). September 2017 – February  2018

A questionnaire will be developed to assess pilot sites participating in the implementation. This questionnaire will be developed in order to identify and assess the most relevant organizational characteristics of the 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(ies) that will be applied in the practices participating to the implementation. Strategies adopted at a national or regional level will be reviewed by a survey among partners participating to CHRODIS PLUS.

Task 1.3 – Definition of 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 involving WP partners, leaders of participating partners and external experts, leaders of the practices involved in the implementation will be organized to discuss strategies for the implementation of the JA-CHRODIS integrated care model. Possible tools, instruments and outcomes to assess the success of the implementation will be discussed and defined. Outcomes might include patients-related outcomes, use of resources (i.e hospitalization) and process oriented outcomes (i.e. quality of care, continuity of care, both as perceived by patients and professionals, sustainability and organizational outcomes).

TASK 2: PILOT IMPLEMENTATION

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 in participating practices following the methodology previously defined (see Task 1.3). The model will be implemented in 5 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 Sacro Cuore (UCSC)

This implementation task will be organized based on a 6-months run-in period, followed by a 12-months implementation period.

TASK 3: SUPPORT TO IMPLEMENTATION ACTIVITIES

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 implementation phase started. Local partners will be involved in supporting the implementation activities. Additional visits will be planned based on the needs of the individual practices.

TASK 4: OUTCOMES ASSESSMENT AND EVALUATION

Task leader: Aragonese Institute for Health Sciences (IACS) and University of Salud Carlos III. (ISCIII). September 2018 – May 2020

Relevant outcomes identified in the preparatory phase and agreed with pilot sites identified in the experts meetings will be assessed to determine the success of the implementation (see Task 1.3).

TASK 5: CHRODIS INTEGRATED CARE MODEL ADJUSTMENT FOR LOCAL HEALTHCARE SETTING

Task leader: Vilnius University Hospital Santaros Klinikos (VULSK). February 2018 - May 2020

In parallel with Task 3, and based on local experience and knowledge, participating partners will determine JA- CHRODIS integrated care model to the specific characteristics of their local health care setting. Outcomes will be country specific model versions, fully adapted and specified for local implementation.

Core document: WP6 ja-chrodis-multimorbidity-care-model

 

Key Experts & Organisations

Graziano Onder - Catholic University of the Sacred
Heart, Italy
Rokas Navickas – Vilnius University Hospital Santariskiu Klinikos, Lithuania (VULSK)
LEADER MISSION STATEMENT

“CHRODIS PLUS is an opportunity, where  joint European effort in identifying and redefining best practices  is converted into actual practice across different healthcare setting with real results for the communities. Work package on implementation multimorbidity care model is like a bridge where multimorbidity related best practices are identified, checked and adjusted to be implemented across a wide range of EU countries. We are excited and ready to steer our partners towards a common agreed goal."

LEADERS

GRAZIANO ONDER & ROKAS NAVICKAS
leading work package on

PILOT IMPLEMENTATION OF INTEGRATED CARE MODEL
FOR MULTIMORBIDITY

Organisations:
CATHOLIC UNIVERSITY OF THE SACRED HEART, ITALY (Graziano Onder)
VILNIUS UNIVERSITY HOSPITAL (Rokas Navickas)

MEMBER ORGANISATIONS

MEMBERS

  • WP6 leader Catholic University of Sacro Cuore (UCSC), Graziano Onder: graziano.onder@unicatt.it
  • WP6 co-leader Vilnius University Hospital Santaros Klinikos (VULSK), Rokas Navickas, Elena Jureviciene: Rokas.Navickas@santa.lt
  • University of Salud Carlos III. (ISCIII),
  • International Centre of Excellence in Chronicity Research (KRONIKGUNE),
  • Europen 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)

IMPLEMENTERS

Italy :

  • Catholic University of Sacro Cuore (UCSC)

Lithuania:

  • Vilnius University Hospital Santaros Klinikos (VULSK)
  • The Hospital of Lithuanian University of Health Sciences Kauno Klinikos (LSMU-KAUNO KLINIKOS)

Spain:

  • Aragonese Institute for Health Sciences (IACS)
  • Regional Ministry of Health of Andalusia (CSJA)

SUBCONTRACTOR

  • NIVEL
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