Multimorbidity Care Research Articles

Multi-Criteria Decision Analyses of integrated care for multi-morbidity: results of four case studies from the SELFIE project

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Factors related to health-related quality of life in older people with multimorbidity and high health care consumption over a two-year period

BackgroundThe prevalence of multimorbidity is increasing worldwide, and older people with multimorbidity are frequent users of health care services. Since multimorbidity has a significant negative impact on Health-related Quality of Life (HrQoL) and is more common in older age it would be expected that factors related to HrQoL in this group might have been thoroughly researched, but this is not the case. Furthermore, it is important to look at old people living at home, considering the shift from residential to home-based care. Therefore, we aim to investigate factors that are related to HrQoL in older people with multimorbidity and high health care consumption, living at home.MethodsThis is a secondary analysis of a RCT study conducted in a municipality in south-eastern Sweden. The study had a longitudinal design with a two-year follow-up period assessing HrQoL, symptom burden, activities of daily living, physical activity and depression.ResultsIn total, 238 older people with multimorbidity and high health care consumption, living at home were included (mean age 82, 52% female). A multiple linear regression model including symptom burden, activities of daily living and depression as independent variables explained 64% of the HrQoL. Higher symptom burden, lower ability in activities of daily living and a higher degree of depression were negatively related to HrQoL. Depression at baseline and a change in symptom burden over a two-year period explained 28% of the change in HrQoL over a two-year period variability. A higher degree of depression at baseline and negative change in higher symptom burden were related to a decrease in HrQoL over a two-year period.ConclusionIn order to facilitate better delivery of appropriate health care to older people with high health care consumption living at home it is important to assess HrQoL, and HrQoL over time. Symptom burden, activities of daily living, depression and change in symptom burden over time are important indicators for HrQoL.Trial registrationClinicaltrials.gov identifier: NCT01446757, the trial was registered prospectively with the date of trial registration October 5th, 2011.

The associations of multimorbidity with the sum of annual medical and long-term care expenditures in Japan

BackgroundThe occurrence of multimorbidity (i.e., the coexistence of multiple chronic diseases) increases with age in older adults and is a growing concern worldwide. Multimorbidity has been reported to be a driving factor in the increase of medical expenditures in OECD countries. However, to the best of our knowledge, there is no published research that has examined the associations between multimorbidity and either long-term care (LTC) expenditure or the sum of medical and LTC expenditures worldwide. We, therefore, aimed to examine the associations of multimorbidity with the sum of medical and LTC expenditures for older adults in Japan.MethodsMedical insurance claims data for adults ≥75 years were merged with LTC insurance claims data from Kashiwa city, a suburb in the Tokyo metropolitan area, for the period between April 2012 and September 2013 to obtain an estimate of medical and LTC expenditures. We also calculated the 2011 updated and reweighted version of the Charlson Comorbidity Index (CCI) scores. Then, we performed multiple generalized linear regressions to examine the associations of CCI scores (0, 1, 2, 3, 4, or ≥ 5) with the sum of annual medical and LTC expenditures, adjusting for age, sex, and household income level.ResultsThe mean sum of annual medical and LTC expenditures was ¥1,086,000 (US$12,340; n = 30,042). Medical and LTC expenditures accounted for 66 and 34% of the sum, respectively. Every increase in one unit of the CCI scores was associated with a ¥257,000 (US$2920); 95% Confidence Interval: ¥242,000, 271,000 (US$2750, 3080) increase in the sum of the expenditures (p < 0.001; n = 29,915).ConclusionsUsing a merged medical and LTC claims dataset, we found that greater CCI scores were associated with a higher sum of annual medical and LTC expenditures for older adults. To the best of our knowledge, this is the first study to examine the associations of multimorbidity with LTC expenditures or the sum of medical and LTC expenditures worldwide. Our study indicated that the economic burden on society caused by multimorbidity could be better evaluated by the sum of medical and LTC expenditures, rather than medical expenditures alone.

Planning, implementation and operation of a personalized patient management system for subjects with first suspect of cancer (OnkoNetwork): system description based on a qualitative study

BackgroundOnkoNetwork is a recently established integrated care model with a personalized pathway system to manage patients with first suspect of a solid tumour in secondary care, that evolved as a regional initiative in Hungary. The primary aim of OnkoNetwork is the improvement of clinical outcomes via timely access to quality assured and defragmented healthcare services. The Horizon 2020 funded SELFIE project has selected OnkoNetwork for in-depth qualitative and quantitative evaluation. The aim of this study was to provide a qualitative evaluation of OnkoNetwork along the six components of the SELFIE conceptual framework: 1) service delivery, 2) leadership and governance, 3) workforce, 4) financing, 5) technologies and medical products, and 6) information and research.MethodsAnalysis of published and grey programme documentation, followed by 20 semi-structured interviews with representatives of programme initiators, general and financial managers, involved physicians and non-physician professionals, patients and their informal caregivers. Transcripts of all interviews were analysed by Mayring’s content analysis method by two independent researchers.ResultsThis study yielded the first comprehensive description of the programme. OnkoNetwork is a blue dahila in Central and Eastern Europe, providing timely and quality-assured healthcare services for the target patients by personalized patient path monitoring and management in a financially sustainable manner without macro-level financing of its operation. Innovative professional roles were implemented for non-physicians and physicians, and a supporting information technology application was developed.ConclusionsThis paper provides a systematic description of OnkoNetwork on the six components of the SELFIE conceptual framework for integrated care in multimorbidity to understand how and why OnkoNetwork was implemented and cares (better) for its patients. Because integrated care models are designed and adjusted to their specific local needs and context, those few successful and sustainable models that were established in Central and Eastern European countries represent important benchmarks for other initiatives in this region. Experience with OnkoNetwork during its planning, implementation and operation including the description of key success factors and barriers as perceived by various stakeholder groups, may support the development of further integrated care models especially in countries with similar economic status and healthcare settings.

A patient-centred intervention to improve the management of multimorbidity in general practice: the 3D RCT

BackgroundPeople with multimorbidity experience impaired quality of life, poor health and a burden from treatment. Their care is often disease-focused rather than patient-centred and tailored to their individual needs.ObjectiveTo implement and evaluate a patient-centred intervention to improve the management of patients with multimorbidity in general practice.DesignPragmatic, cluster randomised controlled trial with parallel process and economic evaluations. Practices were centrally randomised by a statistician blind to practice identifiers, using a computer-generated algorithm.SettingThirty-three general practices in three areas of England and Scotland.ParticipantsPractices had at least 4500 patients and two general practitioners (GPs) and used the EMIS (Egton Medical Information Systems) computer system. Patients were aged ≥ 18 years with three or more long-term conditions.InterventionsThe 3D (Dimensions of health, Depression and Drugs) intervention was designed to offer patients continuity of care with a named GP, replacing separate reviews of each long-term condition with comprehensive reviews every 6 months. These focused on individualising care to address patients’ main problems, attention to quality of life, depression and polypharmacy and on disease control and agreeing treatment plans. Control practices provided usual care.Outcome measuresPrimary outcome – health-related quality of life (assessed using the EuroQol-5 Dimensions, five-level version) after 15 months. Secondary outcomes – measures of illness burden, treatment burden and patient-centred care. We assessed cost-effectiveness from a NHS and a social care perspective.ResultsThirty-three practices (1546 patients) were randomised from May to December 2015 [16 practices (797 patients) to the 3D intervention, 17 practices (749 patients) to usual care]. All participants were included in the primary outcome analysis by imputing missing data. There was no evidence of difference between trial arms in health-related quality of life {adjusted difference in means 0.00 [95% confidence interval (CI) –0.02 to 0.02];p = 0.93}, illness burden or treatment burden. However, patients reported significant benefits from the 3D intervention in all measures of patient-centred care. Qualitative data suggested that both patients and staff welcomed having more time, continuity of care and the patient-centred approach. The economic analysis found no meaningful differences between the intervention and usual care in either quality-adjusted life-years [(QALYs) adjusted mean QALY difference 0.007, 95% CI –0.009 to 0.023] or costs (adjusted mean difference £126, 95% CI –£739 to £991), with wide uncertainty around point estimates. The cost-effectiveness acceptability curve suggested that the intervention was unlikely to be either more or less cost-effective than usual care. Seventy-eight patients died (46 in the intervention arm and 32 in the usual-care arm), with no evidence of difference between trial arms; no deaths appeared to be associated with the intervention.LimitationsIn this pragmatic trial, the implementation of the intervention was incomplete: 49% of patients received two 3D reviews over 15 months, whereas 75% received at least one review.ConclusionsThe 3D approach reflected international consensus about how to improve care for multimorbidity. Although it achieved the aim of providing more patient-centred care, this was not associated with benefits in quality of life, illness burden or treatment burden. The intervention was no more or less cost-effective than usual care. Modifications to the 3D approach might improve its effectiveness. Evaluation is needed based on whole-system change over a longer period of time.Trial registrationCurrent Controlled Trials ISRCTN06180958.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 7, No. 5. See the NIHR Journals Library website for further project information.

Primary care and multimorbidity in six Latin American and Caribbean countries.

ABSTRACTObjectivesTo describe patterns of multimorbidity in six diverse Latin American and Caribbean countries, examine its effects on primary care experiences, and assess its influence on reported overall health care assessments.MethodsCross-sectional data are from the Inter-American Development Bank's international primary care survey, conducted in 2013/2014, and represent the adult populations of Brazil, Colombia, El Salvador, Jamaica, Mexico and Panama. Robust Poisson regression models were used to estimate the extent to which those with multimorbidity receive adequate and appropriate primary care, have confidence in managing their health condition, and are able to afford needed medical care.ResultsThe prevalence of multimorbidity ranged from 17.5% in Colombia to 37.3% in Jamaica. Most of the examined conditions occur along with others, with diabetes and heart disease being the two problems most associated with other conditions. The proportions of adults with high out-of-pocket payments, problems paying their medical bills, seeing multiple doctors, and being in only fair/poor health were higher among those with greater levels of multimorbidity and poorer primary care experiences. Multimorbidity and difficulties with primary care were positively associated with trouble paying for medical care and managing one's conditions. Nonetheless, adults with multimorbidity were more likely to have received lifestyle advice and to be up to date with preventive exams.ConclusionsMultimorbidity is reported frequently. Providing adequate care for the growing number of such patients is a major challenge facing most health systems, which will require considerable strengthening of primary care along with financial protection for those most in need.

A Collaborative Platform for Management of Chronic Diseases via Guideline-Driven Individualized Care Plans

Older age is associated with an increased accumulation of multiple chronic conditions. The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. Integrated care is a means to address the growing demand for improved patient experience and health outcomes of multimorbid and long-term care patients. Care planning is a prevalent approach of integrated care, where the aim is to deliver more personalized and targeted care creating shared care plans by clearly articulating the role of each provider and patient in the care process. In this paper, we present a method and corresponding implementation of a semi-automatic care plan management tool, integrated with clinical decision support services which can seamlessly access and assess the electronic health records (EHRs) of the patient in comparison with evidence based clinical guidelines to suggest personalized recommendations for goals and interventions to be added to the individualized care plans. We also report the results of usability studies carried out in four pilot sites by patients and clinicians.

The “Patient-centered coordination by a care team” questionnaire achieves satisfactory validity and reliability

ABSTRACT Increasing prevalence of chronic conditions and multimorbidity challenges health care systems and calls for patient-centered coordination of care. Implementation and evaluation of health policies focusing on the development of patient-centered coordination of care needs valid instruments measuring this dimension of care. The aim of this validation study was to assess the psychometric properties of the French version of the 14-item Patient-Centered Coordination by a Care Team (PCCCT) questionnaire in a primary care setting. PCCCT provides a total score from 0 (worst coordination) to 42 (best coordination). 165 adult patients consulting in primary care with one or more chronic condition(s) completed questionnaires (including PCCCT) at recruitment. After three weeks, participants completed PCCCT again, either by mail (group A) or during a telephone interview (group B). At recruitment, the mean (SD) PCCCT score was 33.3 (7.7). Exploratory factor analysis revealed a 2-dimension structure, 8 items relating to patient involvement and 6 items relating to coordination (factors loadings ranging from 0.34 to 0.88). PCCCT score correlated significantly with subscales of Haggerty’s continuity questionnaire, Spearman correlation coefficients (95% confidence interval) ranging from 0.40 (0.22–0.57) to 0.52 (0.38–0.63). Internal consistency was excellent: Cronbach alpha 0.90 (0.79–0.92). Reliability was good, with an intraclass correlation coefficient of 0.68 (0.55–0.78) for test-retest reliability (group A) and of 0.65 (0.46–0.79) for reliability between the self-administered and the interviewer-administered versions of the questionnaire (group B,). The PCCCT questionnaire presents satisfactory validity and reliability; it can be used for the evaluation of health organizations involving team work in primary care.

Perception of integrated practice in home care services

PurposeAs a result of demographic changes, older people are increasingly living at home, with multi-morbidity and complex care needs. This calls for enhanced integration of homecare nursing and social services. The purpose of this paper is to describe the clinical collaboration, scope and impact of integration from the perspective of staff in a setting identified as fully integrated.Design/methodology/approachIn this qualitative study, data consisted of interviews with managers and care workers in social services and homecare nursing (n=14) in daily clinical collaboration, followed by five focus group discussions (n=28). Data were analysed using framework analysis.FindingsAlthough the homecare services studied were ostensibly fully integrated, the study showed that the process of integration was incomplete. Interdisciplinary coordination between nursing and social services team managers was described as strong and efficient, but weaknesses were identified in collaboration between care workers. They lacked acquaintance with one another, opportunities for communication and knowledge of the contribution of members of other teams. They felt unclear about their own role in coordinated teamwork and lacked a shared vision.Originality/valueThis paper’s originality lies in the model of integrated care studied and its focus on actual care practices. The findings highlight that integration does not automatically permeate between different levels of service. Time and space must be allowed for conversations between health and social service teams to promote integration.

Fostering quality in management of chronic diseases: the Integrated Multimorbidity Care Model CHRODIS+

Fostering quality in management of chronic diseases: the Integrated Multimorbidity Care Model CHRODIS+

Dysglycemia-Based Chronic Disease: An American Association of Clinical Endocrinologists Position Statement

The American Association of Clinical Endocrinologists (AACE) has created a dysglycemia-based chronic disease (DBCD) multimorbidity care model consisting of four distinct stages along the insulin resistance-prediabetes-type 2 diabetes (T2D) spectrum that are actionable in a preventive care paradigm to reduce the potential impact of T2D, cardiometabolic risk, and cardiovascular events. The controversy of whether there is value, cost-effectiveness, or clinical benefit of diagnosing and/or managing the prediabetes state is resolved by regarding the problem, not in isolation, but as an intermediate stage in the continuum of a progressive chronic disease with opportunities for multiple concurrent prevention strategies. In this context, stage 1 represents "insulin resistance," stage 2 "prediabetes," stage 3 "type 2 diabetes," and stage 4 "vascular complications." This model encourages earliest intervention focusing on structured lifestyle change. Further scientific research may eventually reclassify stage 2 DBCD prediabetes from a predisease to a true disease state. This position statement is consistent with a portfolio of AACE endocrine disease care models, including adiposity-based chronic disease, that prioritize patient-centered care, evidence-based medicine, complexity, multimorbid chronic disease, the current health care environment, and a societal mandate for a higher value attributed to good health. Ultimately, transformative changes in diagnostic coding and reimbursement structures for prediabetes and T2D can provide improvements in population-based endocrine health care. Abbreviations: A1C = hemoglobin A1c; AACE = American Association of Clinical Endocrinologists; ABCD = adiposity-based chronic disease; CVD = cardiovascular disease; DBCD = dysglycemia-based chronic disease; FPG = fasting plasma glucose; GLP-1 = glucagon-like peptide-1; MetS = metabolic syndrome; T2D = type 2 diabetes.

Fostering quality in management of chronic diseases: the Integrated Multimorbidity Care Model CHRODIS+

Fostering quality in management of chronic diseases: the Integrated Multimorbidity Care Model CHRODIS+

Integrated Care for High-need High-cost Patients: The Comprehensive Care for Multimorbid Adults Program (CC-MAP)

Introduction : Multimorbidity, the co-occurrence of chronic conditions, is common and associated with substantial burden to patients and healthcare systems. Yet, evidence on the effectiveness of multimorbid primary care programs is limited. We aimed to describe the Comprehensive Care for Multimorbid Adults Program (CC-MAP) and report 12-month hospitalization, quality of life and quality of care outcomes. Methods : A cluster-controlled design of primary care clinics in Clalit Health Services, Israel's largest non-for-profit insurer and provider of services. A total of 1200 (600 in each arm) high-risk multimorbid patients were recruited for a study of primary care clinics participating in the intervention and in comparable, usual care, controls. Clinics with a high proportion of patients with high morbidity burden, measured by the Johns Hopkins Adjusted Clinical Groups (JH-ACG)® weighted score, where chosen for the intervention and similar clinics were chosen as controls . In each of the intervention clinics, a nurse collaborated with 3-4 primary care physicians (PCP) to care for the 100 highest-risk multimorbid patients. Nurses performed comprehensive assessment; designed an all-inclusive care plan; developed a patient tailored action-plan, provide integration of all services and care transitions, and provided self-management support, and care integration. The PCP collaborated with the CC-MAP nurse, mainly in regards to receiving information from the comprehensive assessment she performed and in the joint creation of the care plan and its follow-up. Unplanned hospitalizations, self-reported physical component score (PCS) and mental component score (MCS) of the SF-12v2, and quality of care (using the Patient Assessment of Chronic Illness Care, [PACIC]), were assessed 12 months after recruitment. Results : Patients in the control group were not significantly different from patients in the intervention in regards to clinical characteristics and prior hospitalizations. PCS and PACIC scores were significantly higher in the intervention versus controls (p Discussions : The CC-MAP provides an effective comprehensive approach to reduce unwarranted healthcare utilization and maintain physical status of multimorbid patients. Conclusions : The CC-MAP provides an effective approach to patient selection and care provision for multimorbid patients, resulting in improved care, physical quality of life and reduced unplanned admissions. The program was recently expanded and currently includes 12 clinics in 3 districts. Lessons Learned : This study demonstrates the key features of successful multimorbidity primary care management programs and principles of equitable high-risk multimorbid case selection. The mental health components of the intervention should be strengthened. Limitations : The health care setting in which the study was performed (a large, integrated type of health care delivery system) may not resemble other health care systems. Nonetheless, similar principles of comprehensive multimorbid care management may be generalized. Suggestions for future research : Future research should examine long-term patients’ outcomes, as well as the involvement of patient’s caregivers’ in this process.

Management of personalised guideline-driven care plans addressing the needs of multi-morbidity via clinical decision support services

Introduction: The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. C3-Cloud project aims to build an integrated care platform for addressing the growing demand for improved health outcomes of multimorbid and long-term care patients. Theory/Methods: C3-Cloud has established an ICT infrastructure enabling continuous coordination of patient-centred care activities by a multidisciplinary care team MDT and patients/informal care givers. The Coordinated Care and Cure Delivery Platform C3DP allows, collaborative creation and execution of personalised care plans for multi-morbid patients through systematic and semi-automatic reconciliation of clinical guidelines. Clinical decision support CDS systems implementing flowcharts from evidence based clinical guidelines are integrated to present suggestions for treatment goal and activities e.g. medications, follow-up appointments, diet, exercise, lab tests. Pilot site local care systems are integrated with the C3DP via the technical and semantic interoperability platform to facilitate informed decision making. Active patient involvement is realized through a Patient Empowerment Platform presenting personalized care plan to the patient and establishing a continuous bi-way communication with the patient to collect patient observations, questionnaire responses, symptoms and feedback about care plan goals and activities. Results: The following research results have been achieved to enable guideline enabled personalised care plan management for addressing the needs of multi-morbidity: 43 logical flowcharts were designed out of 4 disease guidelines Type 2 Diabetes, Heart Failure, Renal Failure and Depression. 181 CDS rules assessing 166 patient criteria and recommending 154 goal/activity suggestions were implemented as CDS services in GDL covering T2D and RF. 52 reconciliation rules were designed for eliminating contradicting guideline recommendations due to multi-morbidity. 23 HL7 FHIR profiles were defined for representing care plan and patient data. C3DP has been integrated with these CDS services via CDS-Hooks specification to recommend personalised care plan goals and activities. Discussions: In this research, we have successfully implemented an ICT infrastructure enabling guideline-driven integrated care for multi-morbid patients. Although our ICT solution covers all the technical requirements identified by clinical partners, effective implementation of integrated care in real-life care setting requires major changes in organisational responsibilities and care pathways. Conclusions: User-centred design and usability testing have successfully been completed. C3-Cloud pilot application will now be operated in 3 European pilot sites with the participation of 62 MDT members and 1200 multi-morbid patients for 15 months. Lessons learned: There are two main research lines for reconciliation of contradicting guideline recommendations: 1 fully-automated reconciliation via ontology reasoning, 2 manually-crafted reconciliation rules by clinical expert groups. Although first approach is more dynamic, research results are still for very primitive cases and not clinically validated. As we are targeting an industry-ready solution after piloting in real-life settings, we have opted for the second option. Limitations: When a new chronic disease is to be addressed within our platform, reconciliation rules covering all disease combinations have to be re-assessed by the clinical expert group. Suggestions for future research: Fully-automated reconciliation approaches need to be further studied and validated in real-life settings.

Organizational and care model analysis for c3-cloud deployment preparation

Introduction: The C3-Cloud project http://c3-cloud.eu/ aims to enable the development of personalised care plans for multi-morbid conditions, supported by innovative ICT components, to improve delivery of integrated and patient-centred care. This is achieved through the coordination by a multidisciplinary care team MDT. To demonstrate feasibility, pilot studies will be conducted in 3 European regions: Region Jamtland Harjedalen RJH, Sweden, South Warwickshire SWFT, UK and Basque Country BC, Spain. Short description of practice: We describe the pre-implementation phase to support the implementation of the C3-Cloud care model during the pilot study. The results comprise of prototypes that will be tested in each site. They include: i organizational model description in C3-Cloud scenario, ii key factors at system level and care coordination iii relation between actors, activities and C3-Cloud solutions. Aim and theory of change: The aim is to define organizational prototypes in each site. The theory of change is based on the identification of the organizational model changes required for C3-Cloud solutions to work consistently across different organizational settings and population groups, accordingly to C3-Cloud care model. Targeted population and stakeholders: Multimorbid patients who are 65+ and have at least two or more of diabetes, heart failure, renal failure and depression. 600 intervention and 600 control patients and 62 MDT members. MDT is comprised of health professionals, social care workers and homecare providers. Timeline: The study is divided into a pre-study phase, a study phase and a post-study. This work has been developed in pre-study phase. Highlights: The analyses of system factors have shown differences among the three sites, in various domains, as the resources of the community. The implementation of C3-Cloud speeds up communication among actors. The patients participate in a higher number of activities and the teamwork is strengthened. C3-Cloud supports the formal introduction of all actors in the preparation of the work plan and increases patient involvement. Sustainability: We will use the human resources available in the settings and the technological resources generated along the project, facilitating subsequent deployments. Transferability: It will be supported by the development of guidelines for any organisation to implement the necessary changes. Conclusions: The three pilot sites have good health systems that comply with most of the organizational model prototype requirements. Organizational and geographical settings and place of service for interventions are defined. Care coordination actors, activities and interpersonal communication are in place. However, several areas as alignment of incentives and patient involvement require further research for C3-Cloud care model. Discussion: With the information collated to date, pilot sites are carrying out further work to develop the capability identified infrastructure, skills and organizational practices to provide the C3-Cloud model care. The aim is to implement the suggested changes to adequately deploy the pilot phase of the project in the three environments. Lessons learned: The contribution of MDT members and patients has been crucial. The involvement of the patient in all aspects of care is key for successful care. Change management has to consider what is currently possible for integrated multi-morbidity care pathway adoption.

Chronic Care Management Services for Complex Diabetes Management: a Practical Overview.

Formalized chronic care management has the potential to improve the quality and cost-effectiveness of complex diabetes management in adults, but has historically not been sustainably supported by health care systems. This review discusses the application of the chronic care model in the care of complex diabetes and its translation in the current reimbursement structure designed by Centers for Medicare and Medicaid Services (CMS). Following the introduction of Wagner's Chronic Care Model (CCM) in the late 1990s, evidence gathered over the past 2 decades has supported the shift in focus of health care systems from acute to chronic disease management and proactive care. Acknowledging evidence and potential for improved cost-effectiveness, in 2015, Medicare began reimbursing for chronic care management services (CCMS) for patients with multiple chronic conditions. The CCMS billing codes allow a program to be reimbursed for up to 90min per month spent by clinical staff performing interim care within a comprehensive care plan. Recent data from local and global programs support the application of formalized CCM in diabetes management. Although reimbursement models for CCM have been designed for use in primary care, the challenges of the reimbursement model has opened the door for specialty areas focused on multimorbidity care such as diabetes care to explore this approach. With the broader availability of remote glucose monitoring and telemedicine, a strategy that combines goal-oriented care and telehealth solutions appears to be most effective in diabetes CCM care. Despite widespread acceptance of the chronic care model of care, there remain significant barriers to its incorporation into standard practice.

Understanding usual care for patients with multimorbidity: baseline data from a cluster-randomised trial of the 3D intervention in primary care

ObjectivesRecent evidence has highlighted the high prevalence and impact of multimorbidity, but the evidence base for improving management is limited. We have tested a new complex intervention for multimorbidity (the...

Strengthening the evidence-base of integrated care for people with multi-morbidity in Europe using Multi-Criteria Decision Analysis (MCDA)

BackgroundEvaluation of integrated care programmes for individuals with multi-morbidity requires a broader evaluation framework and a broader definition of added value than is common in cost-utility analysis. This is possible through the use of Multi-Criteria Decision Analysis (MCDA).Methods and resultsThis paper presents the seven steps of an MCDA to evaluate 17 different integrated care programmes for individuals with multi-morbidity in 8 European countries participating in the 4-year, EU-funded SELFIE project. In step one, qualitative research was undertaken to better understand the decision-context of these programmes. The programmes faced decisions related to their sustainability in terms of reimbursement, continuation, extension, and/or wider implementation. In step two, a uniform set of decision criteria was defined in terms of outcomes measured across the 17 programmes: physical functioning, psychological well-being, social relationships and participation, enjoyment of life, resilience, person-centeredness, continuity of care, and total health and social care costs. These were supplemented by programme-type specific outcomes. Step three presents the quasi-experimental studies designed to measure the performance of the programmes on the decision criteria. Step four gives details of the methods (Discrete Choice Experiment, Swing Weighting) to determine the relative importance of the decision criteria among five stakeholder groups per country. An example in step five illustrates the value-based method of MCDA by which the performance of the programmes on each decision criterion is combined with the weight of the respective criterion to derive an overall value score. Step six describes how we deal with uncertainty and introduces the Conditional Multi-Attribute Acceptability Curve. Step seven addresses the interpretation of results in stakeholder workshops.DiscussionBy discussing our solutions to the challenges involved in creating a uniform MCDA approach for the evaluation of different programmes, this paper provides guidance to future evaluations and stimulates debate on how to evaluate integrated care for multi-morbidity.

Outpatient comprehensive geriatric assessment: effects on frailty and mortality in old people with multimorbidity and high health care utilization

BackgroundMultimorbidity and frailty are often associated and Comprehensive Geriatric Assessment (CGA) is considered the gold standard of care for these patients.AimsThis study aimed to evaluate the effect of outpatient Comprehensive Geriatric Assessment (CGA) on frailty in community-dwelling older people with multimorbidity and high health care utilization.MethodsThe Ambulatory Geriatric Assessment—Frailty Intervention Trial (AGe-FIT) was a randomized controlled trial (intervention group, n = 208, control group n = 174) with a follow-up period of 24 months. Frailty was a secondary outcome. Inclusion criteria were: age ≥ 75 years, ≥ 3 current diagnoses per ICD-10, and ≥ 3 inpatient admissions during 12 months prior to study inclusion. The intervention group received CGA-based care and tailored interventions by a multidisciplinary team in an Ambulatory Geriatric Unit, in addition to usual care. The control group received usual care. Frailty was measured with the Cardiovascular Health Study (CHS) criteria. At 24 months, frail and deceased participants were combined in the analysis.ResultsNinety percent of the population were frail or pre-frail at baseline. After 24 months, there was a significant smaller proportion of frail and deceased (p = 0.002) and a significant higher proportion of pre-frail patients in the intervention group (p = 0.004). Mortality was high, 18% in the intervention group and 26% in the control group.ConclusionOutpatient CGA may delay the progression of frailty and may contribute to the improvement of frail patients in older persons with multimorbidity.

Patient-centred care for multimorbidity: an end in itself?

Patient-centred care for multimorbidity: an end in itself?