1. Multimordibity: Setting a framework from practices Mieke Rijken NIVEL, NL Graziano Onder AIFA, IT 3 rd Stakeholders Forum JA-CHRODIS 4 th February 2016

2. WWW.CHRODIS.EU WP6 task 2: Review existing care (pathway) approaches for multimorbidity patients Activities: 1. Identification and analysis of integrated care programmes targeting patients with multimorbidity in European countries 2. Review the evidence on the effectiveness of integrated care programs targeting patients with multimorbidity

3. WWW.CHRODIS.EU Identification and analysis of integrated care programmes (N=119)

4. WWW.CHRODIS.EU Examples POTKU, FinlandClinic for Multimorbidity and Polypharmacy, Denmark Strategy for Chronic Care Valencia Region, Spain Main aim:Improve patient- centredness Substitution, support primary care Improve delivery of integrated care Target group: Chronic patientsChronic patients with more complex needs Patients with ‘highly complex needs’ Based in:Primary careDiagnostic clinic in hospitalPrimary care + hospital care Care model: PC doctor/nurse teams, individual care plan teams of specialists/others, ‘one day’-service, treatment plan for care by PC doctor Community nurse case manager + hospital nurse case manager, joint monitoring

5. WWW.CHRODIS.EU Results Quality of carePatient outcomesUtilization / costs POTKU, FinlandPatients with individual care plan more positive (PACIC). Care providers experience improved quality (ACIC). Use of primary care decreased (2012- 2014), except phone calls to nurses. Clinic for Multimorbidity and Polypharmacy, Denmark Improved quality and coordination of care according to care providers involved “The multimorbidity clinic results in a more efficient use of hospital resources.” Strategy for Chronic Care Valencia Region, Spain Between 2011 and 2013 decrease of older people with polypharmacy of 34 300 (-10%). In 2012-2014, > 200 000 patients with polypharmacy reviewed and 100 000 drug prescriptions changed, resulting in decrease of expenditures on drugs, from 19.5 million Euros in 2012 to 7.3 million in 2014.

6. WWW.CHRODIS.EU Some conclusions Variety in models and approaches Role of nurses Few with specific multimorbidity perspective Not very well evaluated (yet) Systematic review (2nd activity): inconclusive results  Lack of evidence regarding effectiveness and effective components of care programs/practices

7. WWW.CHRODIS.EU How to define a MM care model?

8. WWW.CHRODIS.EU Problems Lack of evidence Poor standardization Heterogeneity of practices (Mixed interventions) Building consensus among experts

9. WWW.CHRODIS.EU Approach 1.Identification of components of practices (interventions) and classification based on the CCM

10. WWW.CHRODIS.EU Components Delivery system design –Comprehensive assessment –Multidisciplinary team –Individualized care plans –Case manager Decision support –Implementation of EBM –Team training –Consultation system Self management –Tailor Self-management –Health literacy –Patient education –Family education –Approaches self-management –Patients in decision making –Training medical devices Community resources –Access community resources –Involvement of social network – Psychosocial support Clinical information system –Electronic patients records –Exchange patients infos –Uniform coding –Computerized systems

11. WWW.CHRODIS.EU Approach 1.Identification of components of practices (interventions) and classification based on the CCM 2.Expert opinion

12. WWW.CHRODIS.EU Experts Joao ForjazMieke Rijeken Elena Jureviciene Ulrike Rothe Alessandra MarengoniLaurène Souchet Christian Muth*Vontetsianos Theodore Rokas NavickasJosè Valderas* Graziano OnderJelka Zaletel Alexandra Prados-Torres *External experts

13. WWW.CHRODIS.EU Experts meeting - Results 16 components selected For each component: –Description and aims –Key characteristics –Relevance to multimorbidity patients

14. WWW.CHRODIS.EU Experts meeting - Results Delivery system design –Comprehensive assessment –Coordinated team –Individualized care plans –Case manager Decision support –Implementation of EBM –Team training –Consultation system Self management –Tailor Self-management –Options for self management –Shared decision making Community resources –Access community resources –Involvement of social network Clinical information system –Electronic patients records –Exchange patients infos –Uniform coding –Patient operated technology

15. WWW.CHRODIS.EU Conclusion This care model needs to be assessed and validated in a real life setting to determine specifically how and to what extent multimorbidity patients will benefit from it; Specific research questions of interest may focus on how this care model can be applied across different settings in various European countries; Costs and benefits to the patients and families, and practical application of the care model within care and medical setting should all be considered

16. WWW.CHRODIS.EU The Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS)* * This presentation arises from the Joint Action addressing chronic diseases and healthy ageing across the life cycle (JA- CHRODIS), which has received funding from the European Union, under the framework of the Health Programme (2008-2013). Sole responsibility lies with the author and the Consumers, Health, Agriculture and Food Executive Agency is not responsible for any use that may be made of in the information contained therein.