Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review

Abstract

Most models and elements found in the literature focus on integrated care in general and do not explicitly focus on multi-morbidity. In line with this, most programmes identified in the literature build on the CCM. A comprehensive framework that better accounts for the complexities resulting from multi-morbidity is needed.

Defining good health and care from the perspective of persons with multimorbidity: results from a qualitative study of focus groups in eight European countries

“…This core set was developed on the basis of four sources, of which the focus groups described in the current article had the most prominent influence. The other three sources were: (1) findings from a literature review conducted to develop a framework on integrated care for multimorbidity and to identify existing programme evaluations,5 (2) (inter)national SAB discussions in the eight SELFIE partner countries with patients, partners, professionals, payers and policy makers and (3) the aims of the aforementioned 17 programmes and current indicators included in these programmes. A set of criteria was used to come to this list (see online supplementary file box S4), and some concepts mentioned in the focus group were not included in the core set, because these did not meet these criteria.…”

“…These cards were made a priori by the Dutch team and distributed to each organiser. The outcomes on the a priori made cards stemmed from publications on integrated care programmes for multimorbidity that were included in a large scientific literature review that was also conducted in the SELFIE project 5. All outcomes included in those integrated care evaluation publications were ordered according to the Triple Aim and, where possible, overlap was removed.…”

“…There are different integrated care programmes for multimorbidity being implemented across Europe that may offer a solution to the aforementioned risks that this population faces 4–7. The evidence base of such programmes is still limited, and findings are not yet wholly convincing 5–7. Increasing this evidence base is important for the durability, wider implementation and more sustainable reimbursement/financing of such programmes.…”

“…Similarly, experience with care can include many different aspects, such as the extent to which care is proactive or person centred (eg, two domains of the Patient Assessment of Chronic Illness Care instrument) 15. Scientific literature used in a review conducted in the context of the Sustainable intEgrated chronic care modeLs for multimorbidity: delivery, FInancing, and performancE (SELFIE) research project, as the current study is (see box 1), provided insight into which outcomes have been used in recent integrated care programme evaluations 5. We saw that a wide array of indicators, corresponding to the Triple Aim, are being used.…”

Care complexity in hospitalized elderly according to cognitive performance

“…The greater care complexity detected in patients with cognitive decline included in this study is in line with findings in the literature regarding the INTERMED method, since it extends the clinical scope beyond the biomedical aspect (18) . Faced with this need of biopsychosocial vision, the coordination of care is important to favor its integrality (33)(34)(35)(36) .…”