Between 2000-2050 the number of people aged 60+ is expected to double and many people will have more than one illness.

Between 2000-2050 the number of people aged 60+ is expected to double and many people will have more than one illness.

What is multimorbidity? 

Due to an ageing population and improved detection and treatment of diseases many people now have more than one illness. These people require the attention of multiple health care providers or facilities as well as home-based care. A patient with multimorbidity presents the health care system with unique constellation of needs, disabilities or functional limitations.

Care for people with multimorbidity is complicated because different conditions and their treatments often interact in complex ways. Despite this, the delivery of care for people with multiple long term conditions is still often built around the individual conditions, rather than the person as a whole. As a result, care is often fragmented and may not consider the combined impact of the conditions and their treatments on a person’s quality of life.

The Integrated Multimorbidity Care Model 

The Integrated Multimorbidity Care Model (IMCM) aims to overcome many of the issues related to fragmented care. The Model focuses on several limitations currently facing the treatment of multimorbid patients. It recognises that fragmented care may be due to a lack of integration between primary and hospital care services, as well as between healthcare professionals from different specialties or disciplines.  IMCM was developed in Joint Action CHRODIS (2014-2017). Within CHRODIS PLUS, the model was assessed in practice to prove its applicability and effectiveness. The IMCM proposes 16 components for the care and treatment of multimorbid patients.

Main achievements of the 1-year pilot studies:

The pilots: 

LITHUANIA, VILNIUS UNIVERSITY HOSPITAL SANTAROS KLINIKOS – VULSK

A total of 195 people were included in the study at this pilot site and 60% of patients (from 120 who were surveyed) reported positive changes in the care they received in the past 12 months. All patients underwent comprehensive assessment and 97.4% had an individualised care plan. There was a significant decrease in the average number of active medical substances used per patient between their first and last medical visits.

ITALY, UNIVERSITÀ CATTOLICA DEL SACRO CUORE – ROME

A total of 265 people were included in the study at the UCSC pilot site. There was a decrease of 66.7% in the number of Emergency Department visits from 2018 to 2019 (3.4% and 1.1%, respectively). In 2019, 92.8% less missed appointments were registered compared to 2018 (1.9% and 26% respectively).

LITHUANIA, VILNIUS UNIVERSITY HOSPITAL SANTAROS KLINIKOS – VULSK

A total of 195 people were included in the study at this pilot site and 60% of patients (from 120 who were surveyed) reported positive changes in the care they received in the past 12 months. All patients underwent comprehensive assessment and 97.4% had an individualised care plan. There was a significant decrease in the average number of active medical substances used per patient between their first and last medical visits.

ITALY, UNIVERSITÀ CATTOLICA DEL SACRO CUORE – ROME

A total of 265 people were included in the study at the UCSC pilot site. There was a decrease of 66.7% in the number of Emergency Department visits from 2018 to 2019 (3.4% and 1.1%, respectively). In 2019, 92.8% less missed appointments were registered compared to 2018 (1.9% and 26% respectively).

SPAIN, REGION OF ANDALUSIA

As part of the Andalusian pilot, 2,788 patients were included across 372 primary healthcare centres within 32 health districts and 8,388 healthcare professionals underwent training. There was a decrease from 2018 to 2019 in family physicians’ visits at primary healthcare centres, family nurses’ visits at primary healthcare centres, emergency episodes at primary healthcare centres and outpatient visits.

LITHUANIA, KAUNAS UNIVERSITY CLINIC

The pilot included 201 patients. The interventions were related to components across all five domains (see section 2); all patients were screened for mental problems and polypharmacy incompatible drug-drug interactions and underwent consultation by the multidisciplinary care team. The number of hospitalisations per year reduced by 0.4 and Emergency Department visits decreased by 0.2.

SPAINREGION OF ARAGON

The pilot implementation included 291 patients over 65 years of age in 21 primary care teams from 13 primary care health centres, internists from 3 general hospitals, policy makers, healthcare managers and researchers. At the end of the implementation, all patients had a designated case manager and an individualised care plan. Up to 96.7% of them had their social context assessed and 3.3% were referred to the social worker, while 87.5% of patients reported an improvement in health care after the intervention.

SPAIN, REGION OF ANDALUSIA

As part of the Andalusian pilot, 2,788 patients were included across 372 primary healthcare centres within 32 health districts and 8,388 healthcare professionals underwent training. There was a decrease from 2018 to 2019 in family physicians’ visits at primary healthcare centres, family nurses’ visits at primary healthcare centres, emergency episodes at primary healthcare centres and outpatient visits.

LITHUANIA, KAUNAS UNIVERSITY CLINIC

The pilot included 201 patients. The interventions were related to components across all five domains (see section 2); all patients were screened for mental problems and polypharmacy incompatible drug-drug interactions and underwent consultation by the multidisciplinary care team. The number of hospitalisations per year reduced by 0.4 and Emergency Department visits decreased by 0.2.

SPAINREGION OF ARAGON

The pilot implementation included 291 patients over 65 years of age in 21 primary care teams from 13 primary care health centres, internists from 3 general hospitals, policy makers, healthcare managers and researchers. At the end of the implementation, all patients had a designated case manager and an individualised care plan. Up to 96.7% of them had their social context assessed and 3.3% were referred to the social worker, while 87.5% of patients reported an improvement in health care after the intervention.

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Project leaders and partners:

Graziano Onder | Catholic University of the Sacred Heart, Italy

Elena Jurevičienė | Vilnius University Hospital Santaros 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.”

MEMBERS

  • WP6 leader Catholic University of Sacro Cuore (UCSC), Graziano Onder: [email protected]
  • WP6 co-leader Vilnius University Hospital Santaros Klinikos (VULSK), Rokas Navickas, Elena Jureviciene: [email protected]
  • 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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