Overcoming multimorbidity: Chrodis Integrated Multimorbidity Care Model pilot implementation

Abstract

Abstract Background Multimorbidity (MM) has become one of the greatest challenges for patients and healthcare providers, calling for the development of care models that offer holistic, patient-centered care plans. Our objective was to assess the applicability and effectiveness of the Chrodis Integrated Multimorbidity Care Model (IMCM) to improve care for patients with MM in the Public Health System of Aragón, a region in northeastern Spain where MM affects 80% of people over 65 years of age. Methods We developed and implemented a set of actions (”change package”) to target three main improvement areas (i.e., care fragmentation, training of professionals and community care) covering all five dimensions of the model. We used key process and outcome indicators to evaluate each action, including healthcare service use (hospitalizations, emergency room visits), delivery of care (care plans, case managers), improvement in MM management skills of professionals (online training course), and patient self-perceived quality of care (ad-hoc questionnaire). Results 291 patients of over 65 years of age with MM were recruited. At the end of the implementation every patient had a designated case manager and an individualized care plan, and 96.7% had their social situation assessed. During the 1-year pilot intervention, patients averaged 0.69 hospitalizations and 1.24 visits to the emergency room; 87.5% reported a self-perceived improvement of received care. 348 community resources were mapped and made available online in an official website. 89% of professionals who were offered to participate in the training programme agreed, reporting 8.3/10 satisfaction with the course, and improved their MM management skills from 7.36 to 9.18/10. Conclusions The IMCM is applicable in the context of the Spanish Public Health System and is effective in improving quality of care for patients and professionals alike. Key messages Reinforcing the mechanisms that integrate community, primary and hospital care is still necessary if we intend to reduce the negative health outcomes associated to care fragmentation in multimorbidity. The sustainability of the model requires the continued collaboration of key stakeholders and the awareness that multimorbidity is an issue that exceeds purely economic and structural barriers.