The care of patients with chronic diseases has become one of the most important issues for health organizations, as it leads to an important healthcare burden with up to 59% of deaths being caused by chronic diseases worldwide [1
]. Multimorbidity, defined as the presence of two or more chronic diseases coexisting in the same person, represents a major challenge for public health, as it is becoming more and more prevalent in most European countries and is associated to negative health outcomes and increased costs for health systems [2
]. The most frequently associated adverse outcomes to multimorbidity include lower quality of life, higher treatment burden (i.e., polypharmacy), higher risk of mortality, adverse drug events, and inappropriate use of health services, including unplanned and emergency care [4
]. Multimorbidity is the most prevalent chronic condition, especially in older adults, reaching up to 90% of people over 65 years of age [6
The design of care models for people with multimorbidity is becoming a priority for most healthcare systems, as they are still mainly oriented towards acute rather than chronic disease care [9
]. The models designed to meet the needs of these patients require a comprehensive approach and the reorientation of healthcare systems. At present, specific care pathways for multimorbidity are scarce, not standardized, and have limited evidence of effectiveness [10
]. In order to face these complex deficiencies, a multidimensional transformation of medical attention towards a patient-focused system would be necessary [11
The Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS) brought together over 70 partners from 24 EU Member States aiming at minimizing the burden of chronic diseases and the impact of multimorbidity using the best knowledge currently available. In the absence of a specific care model capable of addressing the complex challenge that multimorbid patients represent, JA-CHRODIS recently developed the Integrated Multimorbidity Care Model (IMCM). This model identified a set of common standardized components for the care of patients with multimorbidity to be applied in different European healthcare systems [13
The development of the JA-CHRODIS IMCM involved the collaboration of experts from different countries who identified a total of 20 key components in the delivery of care to multimorbid patients based on the systematic review conducted by Hopman et al. 2015 [10
]. Subsequently, the expert group analyzed the relevance of the components for the integrated care of these patients, and finally selected 16 key components and grouped them into five areas: delivery of care, decision support, self-management support, information systems and technology, and social and community resources [14
]. However, this theoretical model has not yet been implemented in real life conditions. In this regard, a study of its applicability would be of interest to facilitate the implementation of the model in regular clinical practice.
The main objective of this study was to analyze the potential applicability of the IMCM in a hypothetical multimorbidity case study with highly prevalent conditions, such as diabetes and mental health issues, and to describe the elements that need to be considered to apply each of the components of the model and facilitate its actual implementation in daily clinical practice.
2. Materials and Methods
This study followed a qualitative methodology consisting of two consecutive phases. The first step was to design a case study of a realistic and hypothetical woman with multimorbidity (‘Maria’s case’). Then, we distributed the case study among a group of experts from different countries and collected, analyzed, and summarized their opinions on the potential applicability of the IMCM to this specific case.
2.1. Maria’s Case
We developed this case study based on empirical data from multimorbidity studies containing population-based information from real healthcare registries [4
]. Information on socio-demographic (i.e., age, gender, marital status, education level, urban/rural setting, employment status, number of children, caregiving of grandchildren) and clinical characteristics (i.e., number and type of chronic health conditions, mobility, sleep, obesity, healthcare service utilization, quality of life, self-rated health and activity levels) of patients with type 2 diabetes mellitus and mental health issues was gathered. To do so, the CHRODIS core team, comprising a group of eight JA-CHRODIS members from Work Packages WP6 (Multimorbidity) and WP7 (Diabetes), consulted the Survey of Health, Ageing and Retirement in Europe (SHARE) Wave 5 dataset [15
]. The case was about a fictional female patient with multimorbidity, named Maria, described using detailed information on her socio-demographic, clinical, social, psychological, and family characteristics, as well as her main barriers and her use of health resources (Supplementary material, File S1
2.2. Collection and Analysis of Expert Opinions
The CHRODIS core team developed a questionnaire (Supplementary Material, File S2
) to be distributed by email among a group of experts from different countries. This questionnaire, which was written and answered in English, collected detailed information on how each of the IMCM components should be ideally applied to Maria’s case.
The members of the group of experts were selected using a convenience sampling method. The CHRODIS core team contacted by email potential respondent experts, suggested by members from WP6 and WP7, to answer the questionnaire. Eleven experts (of a total of 20 contacted) from eight countries (Croatia, 1; Italy, 1; Germany, 1; Lithuania, 1; Netherlands, 2; Slovenia, 1; Spain 1; United Kingdom, 3) agreed to participate and report on the relevance of the 16 IMCM components for the care of patients with multimorbidity. The group of experts included general practitioners (GP), physicians from different specialties (i.e., neurologists, geriatricians, internists, cardiologists, endocrinologists, and diabetes specialists), epidemiologists, psychologists, and representatives from the patient organization.
To decrease respondent burden, the CHRODIS core team decided to have each of the 16 components answered by experts from two different countries, following the scheme showed in Table 1
. The experts were asked to express their preferences on the components to be assessed, and they were finally assigned to a specific component by the research team to assure a balanced distribution by country and that all the components were covered.
M.J.F., C.R.B., and A.P.T performed a qualitative content analysis of the questionnaires to determine the presence of the most frequent words, themes, or concepts regarding each section of the model, and summarized the answers given to each IMCM component, focusing especially on the common information provided by more than one expert.
We designed word cloud charts to offer a visual representation of the most frequently repeated words used by experts when answering the questionnaires. These charts display relevant words in varying sizes that scale-up proportionally with their frequency of appearance, and therefore offer an intuitive depiction of the most important concepts repeated by different experts. The processing of the questionnaires included a critical search for significant words from each of the five sections of the model. We first removed meaningless words that had no influence on the semantics of sentences and then eliminated stop words (e.g., that, same, she) as the final step of questionnaire pre-processing [16
]. By combining the data from each questionnaire and merging our findings from all five sections of the model, we obtained the final representation of the global word cloud.
This investigation did not require the use of personal data from patients or participants and therefore the approval from an ethics committee was unnecessary.
Patients with multimorbidity have complex needs and their care involves a wide variety of healthcare providers and resources. However, research on interventions for multimorbidity remains scarce [3
], and there are very few specific strategies to improve the management of patients suffering from this increasingly prevalent condition [39
]. The JA-CHRODIS IMCM proposes a multidimensional approach for the care of patients with multimorbidity based on the consensus of European experts. The case designed for study provides a suitable framework in which to describe in detail the potential implementation of the IMCM. This work aims to support the usage of the model in clinical practice by identifying relevant barriers and recommendations for the implementation of each component.
Supporting policy makers in the management of people with chronic conditions and their emerging needs is a challenge that various care models, such as the Guided Care model and Wagner’s Chronic Care Model [41
], had already attempted to address. The IMCM was built upon the foundations set by those models and is based on the same underlying principles, structured into five dimensions (i.e., delivery of care, decision support, self-management support, community resources, and information systems). Despite that, the IMCM is considered a living model, distinctive for its adaptability and subject to the addition of new elements by the CHRODIS group as the opportunities to do so arise. For instance, experts are currently incorporating a new dimension with the objective of improving employment access for people with chronic diseases and supporting employers to promote healthy activities for the prevention of chronic diseases in the workplace [43
]. In this sense, good practices regarding employment management for people with chronic diseases have been developed, creating pathways to optimize employment prospects and working conditions. Some of these practices consist of integrative support services that offer coherent pathways for people with chronic conditions to foster their staying-in, integration, or reintegration in the labor market; other practices are based on rehabilitation programs, including work-life related psycho-social support, for which labor market participation represents a key goal [43
]. Future versions of the model integrating this new dimension on employment and chronic diseases should be reevaluated regarding their potential applicability.
Numerous studies suggest that multimorbidity interventions need to be integrated into existing healthcare systems to support their implementation [42
]. Our work evaluates the applicability and transferability of the IMCM and offers insight from experts from various countries to identify key factors for its promotion and integration in different healthcare systems and scenarios. Notwithstanding, local adaptations will likely be necessary even for interventions that are effective in other specific contexts. For example, the Cochrane review showed that interventions targeting comorbid depression, although effective, require training and support for primary care professionals, which may not be available in every setting [9
The most recent Cochrane Review, focusing on patient-level approaches to multimorbidity management [9
], suggested that health outcomes improve when interventions are targeted to population groups with specific risk factors (e.g., depression, specific functional difficulties). Certain studies of the review suggested that patient-level interventions had limited impact if performed in isolation, concluding that multimorbidity care models with ’whole-system organization’ approaches would be more effective. The opinions gathered for our research reassert the importance of this holistic approach and our analysis found many experts, despite their different profiles, concurring in the use of the same conceptual elements such as “support”, “information”, “contact”, or “team”.
Fragmentation of care due to the involvement of multiple care professionals without effective communication represents a real problem for patients with multimorbidity. In this case study, Maria requires integrated interventions from several professionals, where communication among team professionals and the existence of a known contact acting as care coordinator are crucial to avoid care fragmentation. The implementation of the model, as showed in the case study, requires the use of a wide array of rating scales and tools to assess patient needs in a comprehensive and regular way. These instruments could be helpful not only for comprehensive assessments, but also for the coordination between health and social services, which is crucial to perform patient-centered integrated care.
Clinical guidelines that offer decision-making support adapted to multimorbidity should focus on patients’ wishes, beliefs, and needs, and include chapters on concordant and discordant diseases. Healthcare professionals, however, often perceive that they lack specific trainings to work as a team or to address the needs of patients with multimorbidity and their caregivers [46
]. Developing consultation systems to contact external experts would be a useful asset to support decision-making, however, these systems should be timely and flexible to facilitate their implementation and allow for the appropriate exchange of information.
The distinctive features of the different health systems from each country or region (e.g., single or multiple care providers, type of financing mechanisms, decentralization of management of care delivery, level of integration development, or coordination procedures) could limit the development or implementation of key aspects necessary for the model to work. Therefore, analyzing from different perspectives which sections/components of the model can be implemented, and the adjustments that would be necessary to do so in each context, will be essential for an optimal implementation. In this sense, JA-CHRODIS-PLUS is currently performing a pilot implementation of the model in five European care settings [47
], and one of the main objectives, besides the overall assessment of its applicability in clinical practice, is to provide country-specific integrated care model versions with local adaptations taking into consideration local features.
Currently, several actions throughout Europe identify two crucial features when attending complex cases like Maria’s: A multidisciplinary team consisting of primary and specialized healthcare professionals, social workers, and engaged family members; and the necessity of a designated case manager. The clustering of patients based on clinical and organizational complexity is also essential to maximize the efficacy and cost-effectiveness of interventions and ensure greater patient safety. Implementing risk stratification tools may also allow tailoring practices to the individual contexts and needs of patients.
One of the main limitations of the study lies in the limited number of expert opinions used to assess the applicability of the model. Moreover, an unequal number of experts analyzed each component, and, in some cases, results were based on the responses from only two experts. Their different backgrounds and/or variable degree of expertise could have potentially biased the information obtained for each component. This study represents a preliminary assessment of the model´s applicability in clinical practice, and future studies are encouraged to assess the model based on a greater number of opinions and to evaluate the potential applicability in different healthcare settings and countries, in line with the pilot implementation that is being conducted in the context of JA-CHRODIS-PLUS.
The results of this qualitative study showed, through Maria’s case, that the IMCM can provide a flexible framework to be applied in different contexts for the delivery of patient-centered care in chronic patients.