Abstract
Patients with multimorbidity (defined as the co-occurrence of multiple chronic diseases) frequently experience fragmented care, which increases the risk of negative outcomes. A recently proposed Integrated Multimorbidity Care Model aims to overcome many issues related to fragmented care. In the context of Joint Action CHRODIS-PLUS, an implementation methodology was developed for the care model, which is being piloted in five sites. We aim to (1) explain the methodology used to implement the care model and (2) describe how the pilot sites have adapted and applied the proposed methodology. The model is being implemented in Spain (Andalusia and Aragon), Lithuania (Vilnius and Kaunas), and Italy (Rome). Local implementation working groups at each site adapted the model to local needs, goals, and resources using the same methodological steps: (1) Scope analysis; (2) situation analysis—“strengths, weaknesses, opportunities, threats” (SWOT) analysis; (3) development and improvement of implementation methodology; and (4) final development of an action plan. This common implementation strategy shows how care models can be adapted according to local and regional specificities. Analysis of the common key outcome indicators at the post-implementation phase will help to demonstrate the clinical effectiveness, as well as highlight any difficulties in adapting a common Integrated Multimorbidity Care Model in different countries and clinical settings.
Highlights
The Integrated Multimorbidity Care Model is being implemented in five pilot sites from Spain, Lithuania
Results of the survey revealed some common goals for the five pilot sites, such as to increase multidisciplinary collaboration, promote evidence-based practice, and reduce inequalities in access to care and support services
In this article we describe the methods of the pre-implementation phase of five pilot sites who are implementing an Integrated Multimorbidity Care Model as part of JA CHRODIS-PLUS
Summary
Multimorbidity is the co-occurrence of multiple chronic diseases or conditions in a single individual. It has been described as the most common chronic condition, as it has a high prevalence, especially in older individuals, where it affects more than 60% of people aged 65 or over [1]. Some multimorbidity patients can be complex, because they are more likely to have problems with mobility, self-care, and daily functioning than patients with one chronic disease, as well as cognitive impairment and frailty [2]. This often results in more challenging healthcare treatment. Multimorbid patients frequently experience fragmented care [3,4] and receive complex drug regimens and polypharmacy, which increase the risk of inappropriate prescribing, adverse drug reactions, and poor medication adherence [5]
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