Multimorbidity care model: Recommendations from the consensus meeting of the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS)

Problem

The aim was to assess these components to discuss their definition, aims, key characteristics, target population and relevance for patients with multimorbidity in order to develop a framework for care of multimorbidity patients that can be applied across Europe. This was done within a project funded by the European Commission; the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS). This project specifically focuses on development of common guidance and methodologies for care pathways for multimorbid patients, and includes partners from 26 EU Member States.

Approach

A group of experts was convened to develop the multimorbidity care model. Firstly, a list of components from existing published comprehensive care programs for patients with multiple chronic conditions or frailty were identfied through a systematic review. These components were present in one or more care programs, either in isolation or combined with other components. Twenty components were identified across five domains . Based on discussion from the initial list of twenty components, sixteen were selected by the experts and further elaborated (definition, aims, key characteristics, target populations, and relevance to patients with multimorbidity) for developing a framework for care of multimorbidity patients that can be applied across Europe.

Findings

The 16 components were organized across the domains as follows: DELIVERY OF THE CARE MODEL SYSTEM: Regular comprehensive assessment of patients ; Multidisciplinary, coordinated team ; Professional appointed as coordinator of the individualized care plan and contact person for patient and family (“case manager”); Individualized Care PlansDECISION SUPPORT: Implementation of evidence based practice; Training members of the multidisciplinary teamDeveloping a consultation system to consult professional experts SELF MANAGEMENT SUPPORT: Training of care providers to tailor self-management support based on patient preferences and competencies: Providing options for patients and families to improve their self-management . Shared decision making (care provider and patients)INFORMATION SYSTEMS AND TECHNOLOGY: Electronic patient records and computerized clinical charts; Exchange of patient information (with permission of patient) between care providers and sectors by compatible clinical information systems; Uniform coding of patients’ health problems where possible; Patient-operated technology allowing patients to send information to their care providers. SOCIAL AND COMMUNITY RESOURCES: Supporting access to community- and social-resources;Involvement of social network (informal), including friends, patient associations, family, neighbours.

Consequences

A care model for people with multimorbidity across Europe has been developed based on a systematic review of the literature and expert consensus. The applicability and feasibility of implementing this model needs to be established across Europe.