WORK PACKAGE 2

The most promising ICC multi-morbidity projects, identified in WP1 will be comprehensively described, covering the following elements:

• Barriers to and facilitators of implementation
• How person-centeredness is achieved
• How pro-active care aimed at prevention of progression and complications is achieved
• Use of self-management interventions
• What underlying theories of behavioral change are used
• How guidelines and protocols were adapted to achieve a holistic assessment
• Which organizational reforms of care processes took place to bridge the gap between health care, social care, and informal care
• Involvement of new professional roles
• How leadership and governance at various levels are organized
• Which actions were taken to address health literacy and vulnerable groups
• How modern ICT and e-health are used
• What smart technologies are used to support an independent life
• What financial incentives were put into place
• What cost control actions were taken
• What continuous improvement methodology is used
• Which community and neighborhood services were offered

A protocol for a qualitative study will be developed that each partner will use to collect information about the ICC projects in their country. Information on the elements listed above will be collected. ‘Thick descriptions’ of the most promising ICC projects will be made. The analysis hereof will provide information on how to best design and organize the delivery of care and how to best implement ICC.