Developing a Conceptual Framework of Person-Centred Integrated Chronic Care for Multi-Morbid Patients

This blog was written by Verena Struckmann

Since our last blog in October, written by my Dutch colleague Fenna Leijten from iBMG-EUR, the SELFIE project has entered its first important project phase. Working on SELFIE as a researcher at the Technical University Berlin, meant being responsible for Work Package 1 (WP 1) in collaboration with our Austrian and Dutch partners.

Within the last months we have completed a comprehensive systematic literature review. We gathered evidence from implemented integrated care projects for multi-morbid persons in different countries, collected information about frameworks/models and identified elements positively influencing the progress of integrated care for multi-morbid persons. There was, as expected, a substantial heterogeneity of both definitions of multi-morbidity and integrated care projects across countries.

Parallel to this process, all partners identified actual projects that provide integrated chronic care for multi-morbid persons in their countries (Germany, UK, Norway, Spain, Croatia, Hungary, Austria, and the Netherlands) and in several other countries (e.g., New Zealand, Australia, Canada, and the US). For each country a ‘long-list’ of ongoing projects was made. Partner countries that identified the most projects were the UK, Spain, Norway, and the Netherlands.

One of the key outcomes of WP 1 is the development of a conceptual framework on integrated chronic care (ICC) for multi-morbid persons. In recent years there have been many advances in the development of useful conceptual frameworks and currently other European projects are also developing frameworks to for example provide managers and policy-makers with guidance (INTEGRATE)or to give recommendations for delivery of system design (JA- CHRODIS). To face the burden of multi-morbidity we aim to develop a patient-centered, user-friendly, and clear framework that may help us to describe and evaluate current integrated chronic care projects for persons with multi-morbidity.

Our stakeholder advisory board was invited to our last meeting in Vienna and was comprised of the ‘5Ps’: (1) patients with multi-morbidity and/or their representatives (European Patient’s Forum, NHS NIHR Patient and Public Health Involvement); (2) partners and family members of persons with multi-morbidity and/or their representatives  (International Alliance of Carer Organizations), (3) professionals who provide care or are experts in this field (European Forum Primary Care, Standing Committee of European Doctors, Center for Health Aging Copenhagen, Guidelines International Network- Multi-Morbidity Working Group, Netherlands Institute for Health Services Research NIVEL, International Foundation for Integrated Care), (4) payers such as health care budget holders and health insurers (Dutch Health Insurer VGZ) , and (5) policy makers (OECD). We invited these stakeholders to reflect on, and discuss, our framework and at the same time to receive advice on the selection of projects that provide integrated chronic care for multi-morbid persons in the partner countries.

Looking back at our lively and fruitful discussions, I can say that we have made good progress, as we received very useful feedback. Therefore we would like to thank our stakeholder advisory board very much for sharing their experiences, suggestions, and critical thoughts with respect to our framework and project lists.

Currently we are adjusting our framework on the basis of this discussion and further findings retrieved from the literature review. Moreover, we are in the process of making the final project selection, based on the input and developed final criteria to select the most promising integrated chronic care projects for multimorbidity. Currently each partner is rating the projects identified.

In the meantime all partners started with WP2 where we will provide a thick description of the 16 finally chosen ongoing ICC projects (2 per country). During the second day at our meeting in Vienna, our Austrian partners from the Institute for Advanced Studies (IHS) organized a well-structured, informative, and participatory workshop for all project partners. Everybody actively practiced (sometimes in teams of two persons) how to systematically conduct a qualitative interpretative analysis of interview transcripts. Initial confusion could be resolved and finally each partner left the meeting with a clear vision of pending tasks ahead. Within WP2 the focus will be on how to best implement ICC projects and how to best design and organize the delivery of care around the multi-morbid persons. In this process we will perform extensive document analyses and conduct interviews with stakeholders in the projects (e.g., managers, medical and social staff, clients or their caregivers to collect more in depth information).

In the coming months, each SELFIE partner will be organizing a national stakeholder workshop to reflect on the findings in the SELFIE project thus far, and brainstorm about our next steps. Find more information on these in the website post.

Participants from different partner organizations will be posting updates on our work via this blog regularly, you can either check this page to stay up to date, or sign up for the newsletter below to receive information via email. Please contact us if you have any questions, comments, or suggestions!

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