Work Package 6 members pointing at the WP leader during the kick-off meeting for CHRODIS PLUS


 MULTIMORBIDITY CARE MODEL

WORK PACKAGE 6

Objectives

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

TIMELINE OF KEY ACTIVITIES
  • September 2017 – WP6 Kick-off Meeting
  • August 2018 – Experts meeting to determine the preparatory phase and pilot strategy
  • August 2018 – Report on the preparatory phase and scaling-up strategy
  • August 2019 – Pilot implementation
  • April 2020 – Pilot implementation and outcomes evaluation
  • June 2020 – The development of country-specific CHRODIS integrated care model versions
TIMELINE CHART
  • August 2018 – Report on the preparatory phase and scale up strategy
  • August 2020 – Pilot implementation
  • June 2020 – Country-specific CHRODIS integrated care model versions developed

Main Tasks

TASK 1: PREPARATORY PHASE

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 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 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 3: SUPPORTING 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 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 4: OUTCOME ASSESSMENT AND EVALUATION

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).

TASK 5: THE CHRODIS INTEGRATED CARE MODEL ADAPTED TO THE LOCAL HEALTHCARE SITUATION

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 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.

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

 

Key Experts & Organisations

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

“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."

LEADERS

GRAZIANO ONDER (Graziano.Onder@unicatt.it) & ELENA JUREVICIENE  (Elena.Jureviciene@santa.lt)
lead the work package on

PILOT IMPLEMENTATION OF THE INTEGRATED CARE MODEL
FOR MULTIMORBIDITY

Organisations:
CATHOLIC UNIVERSITY OF THE SACRED HEART, ITALY (Graziano Onder)
VILNIUS UNIVERSITY HOSPITAL (Elena.Jureviciene)

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
  • 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)

IMPLEMENTERS

Italy :

  • Catholic University of the Sacred Heart (UCSC)

Lithuania:

  • Vilnius University Hospital Santaros Klinikos (VULSK)
  • The Hospital of the 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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