Abstract submitted to ICIC22

The CareMatrix consortium submitted an abstract to ICIC22 the 22^nd International Conference on Integrated Care, planned to take place on 23-25 of May 2022 in Odense, Denmark. The abstract, entitled “Better care for people with multimorbidity: needs identified in three European health systems. Initial results of the CAREMATRIX project“, presents the methodology and results of the needs’ assessment process conducted as an initial phase for the subsequent Pre-Commercial Procurement process to be carried out in the CareMatrix project.

Objective

The objective of the presented work was the identification of the main needs and challenges in relation to improving care for people with multimorbidity that could be found in the three PCP’s Buyers’ Group’s participating regions/sites: Region Skåne (Sweden), Basque Country (Spain), Vestre Viken Hospital Trust (Norway).

Methodology

For this purpose, the members of the consortium organised three parallel workshops (one in each future procurers’ Member State) and in-depth interviews. The workshops were organised following a predefined and agreed structure and their results jointly analysed. A total number of 54 persons were consulted, among them: health professionals (doctors and nurses from primary and hospital care), healthcare managers, IT experts, patients’ representatives and one social worker. In addition, a comprehensive international literature review was also performed.

Results

The identified needs are described in the Report on insights, needs and key challenges. These needs/areas for improvement were classified in five interrelated Building Blocks:

1. Early and comprehensive assessment with a preventive approach
2. Interdisciplinary collaboration/Interdisciplinary team
3. Individualised and patient centered care
4. Continuity of care: communication, coordination and proactive follow-up; and
5. Patient and carer participation and empowerment.

For communication purposes, these Building Blocks were ordered along a theoretical care pathway, starting with an “Assessment and Identification” phase, following with the “Care Planning”, and continuing with the actual provision of “Integrated care”. All along this process, ensuring “Patient and caregiver participation and empowerment” was identified as a key Building Block. In the real world the different phases and Building Blocks overlap with each other and are closely interconnected. The proposed Phases should therefore be seen as a continuous process. The improvement of care for PMM would require progress in all the five identified Building Blocks.

The results from the needs’ identification phase were consistent with the findings in the literature and the recommendations in clinical practice guidelines and models for improved care for PMM.

Among identified needs, some could be addressed through Information Technology solutions, while others would require changes in the organisation of care and thus, could be seen as proposals for improvement.