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Category Archives: Care model

The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity

By Jonathan Stokes

There is a lack of evidence on effective intervention for managing patients with multimorbidity. A major barrier to progress in this area is the lack of consensus over how best to describe models of care for multimorbidity. If evidence is to drive clinical innovation, we need to build the evidence base through ongoing evaluation and review. That process is hampered, however, by incomplete descriptions of models in publications. Without accurate descriptions, researchers cannot replicate studies or identify ‘active ingredients’. There have been many examples in recent years of reporting frameworks that have improved the utility of health services research (http://www.equator-network.org/). In this paper [1], we describe a framework as a starting point for addressing this need in the high-profile area of multimorbidity.

Our framework describes each model in terms of the foundations:
• its theoretical basis (i.e. the clear and explicit aims, values and assumptions of what it is trying to achieve)
• the target population (‘multimorbidity’ is a somewhat vague term, so there is the need to define the group carefully, e.g. a patient with diabetes and hypertension might have very different care needs than a patient with dementia and depression)
• the elements of care implemented to deliver the model

We categorised elements of care into 3 types: (1) clinical focus (e.g. a focus on mental health), (2) organisation of care (e.g. offering extended appointment times for those who have multimorbidity), (3) support for model delivery (e.g. changing the IT system to better share electronic records between primary and secondary care).

Using the framework to look at current approaches to care for multimorbid patients, we found:

• The theoretical basis of most current models is the Chronic Care Model (CCM). This was initially designed for single disease-management programmes, and arguably not sensitive to the needs of multimorbidity.
• That current models mostly focus on a select group, usually elderly or high risk/cost. It is important to remember that in absolute terms, there are more people with multimorbidity aged under 65 years. Similarly, high risk patients are an obvious target, but there may be too few of them to make a significant impact on overall system costs. It is important that models incorporate the needs of younger and (currently) lower risk/cost patients (potentially with most scope for effects of preventing future deterioration).
• There is a need for increased attention for low-income populations (where multimorbidity is known to be more common), and for a focus on mental health (multimorbid patients with a mental health issue are at increased risk for detrimental outcomes).
• The literature suggests that the large emphasis in current models of care on self-management may not always be appropriate for multimorbid patients who frequently have barriers to self-managing their diseases. The emphasis on case management (intensive individual management of high-risk patients) should take into account the evidence that while patient satisfaction can be improved, cost and self-assessed health are not significantly affected.

We also looked at how approaches have changed over time, comparing newer to older models. Newer models tend to favour expansion of primary care services in a single location (e.g. increased co-location of social care services and extended chronic disease appointments), rather than coordination across multiple providers or at home (e.g. decreased care planning and integration with other social and community care services, decreased home care).

Health systems have only recently begun to implement new models of care for multimorbidity, with
limited evidence of success. Careful design, implementation, and reporting can assist in the development of the evidence base in this important area. We hope our framework can encourage more standardised reporting and research on the theoretical basis and target population for interventions, as well as the contribution of different elements (including interactions between them) needed to provide cost-effective care and support redesign of health systems for those who use them most.

This free to read article can be found at the following link:

[1] Stokes J, Man M-S, Guthrie B, Mercer SW, Salisbury C, Bower P. The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity. The Annals of Family Medicine. 2017;15(6):570-7.

Managing patients with multimorbidity in primary care

By Emma Wallace and Susan Smith

Along with colleagues in the UK, we have recently published a Clinical Review on managing patients with multimorbidity in primary care in the BMJ [1]. The review outlines challenges for Family Physicians or General Practitioners (GPs) in care delivery. We identified areas where GPs experience difficulties in caring for patients with multimorbidity and suggest evidence-based practice management strategies:
1.    Disorganisation and fragmentation of care.
Identify patients as having complex multimorbidity and adopt a practice policy of continuity of care for these patients by assigning a named GP to the patient. Consider the following groups; a) Patients with ‘complex’ multimorbidity defined as ≥3 chronic conditions affecting ≥3 body systems; b) Patients with comorbid physical conditions and depression; c) Patients prescribed ≥10 medications; d) Patients who are housebound or resident in nursing homes.
2.    Inadequacy of current disease-specific guidelines.
At times, clinical judgement may mean an acceptance that in certain circumstances, pursuing stringent disease specific targets is unlikely to be beneficial and may in fact be harmful. Consider an approach of targeting function not disease and a focus on medicines management, including deprescribing where possible.
3.    Challenges in delivering patient centred care and barriers to shared decision making. Asking a patient at the outset of a consultation ‘What is bothering you most?’ or ‘What would you like to focus on today?’ can help prioritise management of aspects of care that will have most impact for the patient. Once patient priorities are identified, using available shared decision making tools may help support the process. Patient preference should guide the utilisation of lay-led self-management groups.
4.    Consultation time.
Consider adopting a practice policy of routine extended or ‘specific extended’ consultations for particularly complex patients. Ensure practice systems are in place to maximise the value of the GP consultation for both patient and doctor in reaching management decisions. Multidisciplinary team involvement is important and should be arranged where appropriate.

1) Wallace E, Salisbury C, Guthrie B, Lewis C, Fahey T, Smith SM. Managing patients with multimorbidity in primary care. BMJ 2015;350:h176.

Measuring Care Coordination for People with Multiple Chronic Conditions

By Eva DuGoff, Sydney Dy and Cynthia Boyd

This is the second of three posts on issues measuring quality of care in older adults with multiple chronic conditions.

Care coordination has long been considered integral to the efficient and effective delivery of health care, especially for older adults with multiple chronic health conditions. Under the Patient Protection and Affordable Care Act of 2010, Medicare has funded a number of pilot and demonstration programs testing approaches that incentivize and compensate providers for offering these services. Three of the law’s highest-profile initiatives designed to improve care coordination are Accountable Care Organizations (ACOs), the Independence at Home (IAH) demonstration program and the Community-based Care Transitions Program (CCTP).

In our article recently published in the Journal of Healthcare Quality [1], we examine how these three programs measure care coordination quality in five different domains: 1) Communication includes interpersonal communication and information transfer; 2) Continuity of care includes the capacity to monitor and respond to change, support self-management goals, and link to community resources; 3) Patient centered includes creating a proactive plan of care, assessing needs and goals, and aligning needs and resources; 4) Care transitions includes facilitation transitions as coordination needs change and facilitate transitions across settings; and, 5) Cross-Cutting assesses whether the measure applies to multiple conditions. These measurement domains are drawn from the Care Coordination Measurement Framework and NQF Multiple Chronic Condition Measurement Framework [2, 3].

The selection of the quality measures is a critical design element of these care coordination programs because it determines the empirical evidence base for assessing the success of these programs, as well as financial rewards. While quality measure selection raised a great deal of concern inside the Washington DC beltway, these issues have received little attention in the peer-reviewed literature.

In this article, we consider the ideal scenario to be as described in the following: “Ideally, quality measures in these ACA programs would reward and promote care coordination, particularly for people with MCCs (multiple chronic conditions), and have the same core measurement set to allow for comparisons between programs, and utilize measures endorsed by a national standard-setting organization, such as the National Quality Forum (NQF)” [1]. We focus on how care coordination quality is measured in three high-profile programs, ACOs, Independence at Home, and Community-based Care Transitions, and the NQF care coordination measure set. We collected all measures classified as assessing care coordination and those linked to financial incentives in the three ACA programs. Two reviewers categorized these measures independently then reconciled any differences.

What we find is far from the ideal. There is little overlap in the quality measures used to measure care coordination. While this heterogeneity may reflect the characteristics and needs of different target populations, these differences will inhibit comparison between these programs.

And, too, many aspects of care coordination are not captured by existing, selected measures. “Patient-centered care was not captured by the ACO measures, but was assessed in IAH and CCTP. None of the ACA programs measured aligning resources with patient and population needs. Care coordination activities assessing how well the health care team responds to changes in health needs, care transitions, and monitoring and follow-up were infrequently captured” [1]. In a recent article, Kathryn McDonald and colleagues come to a similar conclusion based on their analysis of care coordination quality measures for primary care practices. They find that there are no adult care coordination quality measures assessing care transitions or measuring how providers respond to changes in a patient’s health needs [4].

Further research is needed to identity meaningful care coordination quality measures that will allow policymakers to comprehensively assess these care coordination programs. There are few measures that measure care coordination in ways relevant to people with multiple chronic conditions—even those these are the people are the most in need of care coordination. In the short-term policymakers could consider aligning care coordination quality measures to the extent feasible across these three programs and future initiatives.


[1] DuGoff EH, Dy S, Giovannetti ER, Leff B, Boyd CM. Setting standards at the forefront of delivery system reform: aligning care coordination quality measures for multiple chronic conditions. J Healthc Qual. 2013 Sep-Oct;35(5):58-69.
[2] McDonald K, Schultz E, Albin L, Pineda N, Lonhart J, Sundaram V, Smith-Spangler C, Brustrum J, Malcolm E. Care Coordination Atlas Version 3 (Prepared by Stanford University under subcontract to Battelle on Contract No. 290-04-0020) Rockville, MD: Agency for Healthcare Research and Quality; 2010. Available at: http://www.ahrq.gov/professionals/systems/long-term-care/resources/coordination/atlas/index.html.
[3] Multiple Chronic Conditions Measurement Framework. (2012) (pp. 1-74). Washington, DC: National Quality Forum.
[4] McDonald KM, Schultz E, Pineda N, Lonhart J, Chapman T, Davies S. Care Coordination Accountability Measures for Primary Care Practice (Prepared by Stanford University under subcontract to Battelle on Contract No. 290-04-0020) Rockville, MD: Agency for Healthcare Research and Quality; 2012.

ICARE4EU: Innovating care for people with multiple chronic conditions in Europe

By François Schellevis

A consortium, coordinated by NIVEL, the Netherlands Institute for Health Services Research, has obtained a 1.2 million Euros grant from the European Commission for the ICARE4EU project which started on March 1st, 2013. ICARE4EU will describe and analyse innovative approaches in multidisciplinary care for people with multiple chronic conditions currently existing in Europe. By disseminating knowledge about effective and innovative solutions, we hope to contribute to an improved design, a wider applicability and more effective implementation of patient-centred multidisciplinary care for people with multimorbidity. The ICARE4EU project is part of the Health Programme 2008-2013 of the European Commission.

Project activities

Expert organizations will be approached in the 28 EU Member States, Iceland and Norway. These organizations will provide information about the characteristics of care programmes aimed at patients with multimorbidity that have been initiated in their country. This will include information about for instance the target group of the programmes, the disciplines involved, the care pathway or procedures, the way patients and informal carers are actively involved, and their evidence or results. More detailed information will be gathered about the following subjects: patient-centeredness, use of e-health technology, management practices & professional competencies and financing systems. Additionally, country level information about the health care system and its characteristics will be gathered. Best practices will be identified for each of the four afore mentioned subjects. Based on this information key characteristics for successful management and implementation strategies will be identified. A plan for future monitoring of the developments in multimorbidity chronic illness care will also be developed.

The consortium

Project partners include the Technische Universität Berlin (Germany), the University of Eastern Finland, the Italian National Institute of Health and Science on Aging, the University of Warwick, the AGE Platform Europe and Eurocarers, the European association working for carers, and we collaborate with the European Observatory on health systems and policies. NIVEL, the Netherlands Institute for Health Services Research, coordinates the ICARE4EU project.

The research team

NIVEL: François Schellevis, Mieke Rijken, Daphne Jansen, Sanne Snoeijs
Technical University Berlin: Reinhard Busse, Ewout van Ginneken, Verena Struckmann
Italian National Institute of Health and Science on Aging: Maria Gabriella Melchiorre, Roberta Papa
University of Eastern Finland: Sari Rissannen, Anneli Hujala
University of Warwick: Aileen Clarke, Mariana Dyakova

Further information




PACE in multimorbidity. Patient-Centred Innovations for Persons with Multimorbidity

By Moira Stewart and Martin Fortin

A Canadian research group led by Drs. Moira Stewart and Martin Fortin recently received funding in the amount of 2.5 million dollars over five years to improve the delivery of primary health care for people with multimorbidity. Awarded by the Canadian Institutes of Health Research (CIHR), this important grant is part of a government initiative to support research on community-based primary health care (CBPHC) across Canada.

Based on a partnership between the respective research teams of Dr. Fortin (Université de Sherbrooke, Québec) and Dr. Moira Stewart (Western University, Ontario), as well as partners from three other Canadian provinces and collaborators from five countries, this group will use a programmatic research approach and timeline to develop, implement and compare innovative models of integrated chronic disease prevention and management (CDPM). The research Team competed with 95 teams from across Canada to obtain this funding. The Team is called “PACE in multimorbidity” for “Patient-Centred Innovations for Persons with Multimorbidity”.

The Team proposes innovations in CDPM that will: reorient care from a single disease focus to a multimorbidity focus; centre on not only disease but also the patient in context; and realign the health care system from separate silos to coordinated collaborations in care. The proposed multifaceted innovations will be grounded in the current realities of CDPM (i.e. chronic care models including self-management programs) that are linked to primary care reform efforts. The Team will build on this firm foundation, will design and test promising innovations and will achieve transformation by creating structures to sustain relationships among researchers, health professionals, patients and decision-makers. The Team will conduct cross-jurisdictional comparisons and is mainly a Quebec – Ontario collaboration with participation from three other provinces: British Columbia, Manitoba and Nova Scotia.

The program will identify factors responsible for the success or failure of current CDPM initiatives linked to the primary care reform, by conducting a realist synthesis of their quantitative and qualitative evaluations and transform consenting CDPM initiatives by aligning them to promising innovations on patient-centred care for multimorbidity patients. The Team will test these new innovations in at least two jurisdictions and compare among jurisdictions. In addition, the program aims to foster the scaling up of innovations and to conduct research on different approaches to scaling up.

The Team’s objectives are based on the concerns expressed by decision-makers and will create new capacity for CBPHC research in Canada by building sustainable networks of interdisciplinary researchers and policy makers, including mentoring junior Team members to build future capacity. The Team is confident that some of the innovations studied over the five years will improve patient self-rated health outcomes while at the same time reduce costs to the system.

Research Team:

Moira A. Stewart, Martin Fortin, Martine Couture, Paul Huras, Onil Bhattacharyya, Antoine Boivin, Judith Brown, Maud-Christine Chouinard, Frances Gallagher, Richard Glazier, William Hogg, Catherine Hudon, Alan Katz, Christine Loignon, Jonathan Sussman, Amardeep Thind, Walter Wodchis, Sabrina Wong, Merrick Zwarenstein, Roxane Borgès Da Silva, Rick Glazier, Fred Burge.

International Advisory Committee

Stewart Mercer (UK), Marjan van den Akker (The Netherlands), John Furler (Australia), Paul Little (UK), Elizabeth A. Bayliss (USA).

Other national collaborators: decision-makers, researchers, collaborators for capacity building and patient advisory committee.

For further information, please do not hesitate to contact Team coordinators: Louisa Bestard Denomme (lbestar@uwo.ca) and Tarek Bouhali (tarek.bouhali@usherbrooke.ca).

Patient-Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise Approach from the American Geriatrics Society

By Cynthia Boyd

A new report issued by the American Geriatrics Society (AGS) outlines how clinicians can tailor care to better meet the unique needs older adults with multimorbidity.  More than half of adults 65 and older have at least three chronic conditions, such as heart disease, diabetes, and arthritis.

Entitled Patient-Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise Approach from the American Geriatrics Society, the new report was published in today’s early, online edition of the Journal of the American Geriatrics Society (JAGS) and is available at www.americangeriatrics.org, in conjunction with a longer version of the documents with more complete references.  A wealth of related information, tips, and tools for both clinicians and the public are also available on the AGS website.

To help both clinicians and patients make complex treatment decisions, the expert panel that developed the report has outlined five essential elements, or guiding principles, for quality care for older adults with multimorbidity: 

  • Preferences: Elicit and incorporate patient preferences* into medical decision-making for older adults with multimorbidity.

By using the term “patient” preferences, we aim to keep the patient central to the decision-making process while recognizing that family and social supports play a vital role in management and decision-making whether or not cognitive impairment is present.

  • Interpreting the evidence: Recognizing the limitations of the evidence base, interpret and apply the medical literature specifically to older adults with multimorbidity.
  • Prognosis: Frame clinical management decisions within the context of risks, burdens, benefits, and prognosis (e.g. remaining life expectancy, functional status, quality of life) for older adults with multimorbidity.
    • Clinical Feasibility: Consider treatment complexity and feasibility when making clinical management decisions for older adults with multimorbidity.
    • Optimizing Therapies and Care Plans: Utilize strategies for choosing therapies that optimize benefit, minimize harm, and enhance quality of life for older adults with multimorbidity.

    The report also describes the urgent need for research to develop and implement evidence-based practices for each of these areas.

    Cynthia Boyd, MD MPH
    Associate Professor of Medicine
    Division of Geriatric Medicine and Gerontology
    Johns Hopkins University School of Medicine