Rationale

People living with multimorbidity usually require care from different professionals, specialties and providers, both from the health care sector (acute hospitals, primary care providers, mental health care providers, community pharmacies, medium/long-term care hospitals) and frequently also from the social care sector.

Traditionally different care providers and settings have worked in silos and in an uncoordinated manner, leading to fragmented care. To improve the health outcomes and healthcare experience of People with Multimorbidity, continuity and coordination of care should be enhanced.

Patients with multimorbidity face a particular risk of lacking continuity and coordination of care in transitions between care levels and settings. Among these transitions, hospital admission, discharge after a hospital stay, emergency visit and stay in a medium/long-term care institution could be mentioned. Particular attention should therefore be given to ensuring continuity of care and care coordination in these transitions, when patients frequently also need a review of their individual care plan, according to the possible changes in their health status, treatments or preferences.

It can be noted that in some cases/health systems, patients with multimorbidity count with an identified healthcare coordinator within the interdisciplinary care team, such as case managers or reference doctors, which could be placed at primary and/or hospital care level (these organisational differences between the regions in the buyers’ group should be considered in the design of any solution). It is important that the continuity of care is ensured beyond the boundaries of the healthcare settings, and also contemplates home care, community care, elderly and social care.

Stakeholders

General Practitioners

Specialised Physicians

Nurses (primary, secondary and tertiary care level)

Mental health care professionals

Emergency services’ staff

Home care and community care staff

Elderly care workers

Social care workers

Administrative staff

Pharmacists (both working in a healthcare setting/organisation and in some countries/ health systems also in the community)

People living with multimorbidity

Carers (formal and informal)

Functionalities

• Solution that supports the visualisation of the individual care plan by care professionals and by the patient.
• Access to interoperable or shared relevant health data and information on the patient registered by different care sectors, levels, settings and care professionals providing care to the patient.
• Access to data and information registered by the patient and/or carers (formal or informal) at home.
• Tools allowing for timely and automatic transfer of information and communication between care professionals, levels and settings, particularly at times of care transitions such as hospital admission, hospital discharge, emergency visit, stay in a medium/long-term care institution, move to an institution or activation of other relevant social support or community support resources.
• System allowing for alerts/reminders to relevant healthcare professionals for the review of the individual care plan, when relevant, in care transitions.
• System facilitating clear and understandable information to be provided to patients and carers at key transition points (areas that could be addressed: next steps in the care pathway, updates to the individual care plan).
• Solutions enabling an easier access by the PMM to the healthcare system, particularly at times of health crisis, acuteness or when having a doubt about his/her health by care professionals.
• If there is an identified care coordinator for the patient: contact information and communication channel with the patient’s care coordinator.

Integrated care aspect

• Interdisciplinary Teamwork
• Healthcare system navigator
• Continuity and coordination of care
• Data sharing

Integrated care functionalities

• Shared care plan
• Data interoperability
• Interorganisational communication