Key messages

• European health systems do not meet the needs of patients with multimorbidity because they are “disease oriented” and organized around single medical specialties which fragments care.
• Fragmented care is associated with contradictory medical advice, over-prescribing, over-hospitalization and poor patient satisfaction.
• Policy-makers can improve care for people with multimorbidity by better integration.
• Making care patient-centred is another way of approaching the fragmentation of care and of increasing patient satisfaction. It requires a clear strategic (and ideally shared) vision.
• Policy-makers can foster both integrated and patient-centred care by:
  • Aligning policy, regulatory and financial environments so that they are supportive of integrated care and help make effective care for people with multimorbidity sustainable;
  • Developing multidisciplinary guidelines;
  • Developing new professional roles (e.g. care coordinator) or functions and assigning explicit responsibility for coordination and links between sectors;
  • Implementing individualized care planning (supported by integrated electronic health records);
  • Putting in place electronic decision support systems that enable patient-centred care and integrating them with information systems and eHealth applications;
  • Adapting privacy and data protection legislation to allow sharing of patient information;
  • Investing in training and tools that help care professionals adopt patient-centred approaches (including training in patient-centred communication and multiprofessional and intersectoral teamwork);
  • Developing the knowledge and skills of patients and their informal carers and encouraging active participation in decision-making and self-management;
  • Promoting collaboration between health care, social care, patient organizations and carers;
  • Including patient-relevant outcomes as performance indicators, as well as clinical outcomes, so that providing integrated care becomes part of quality measurement;
  • Putting in place payment mechanisms to incentivize patient-centred integrated care.
• The continuous evaluation of innovative practices is needed over the long term to identify effective elements and further strengthen patient-centred integrated care.

Contents

• What is ICARE4EU?
• How do Policy Briefs bring the evidence together?
• Acronyms
• Key terms
• Executive summary
• Policy brief
  • Introduction
  • Findings
  • Discussion
  • Conclusions
• References
• Appendix
• ICARE4EU Policy Briefs

This report arises from the Innovating care for people with multiple chronic conditions in Europe (ICARE4EU) project, which has received funding from the European Union (EU), in the framework of the Health Programme. The authors wish to thank all country expert organizations and the programmes that participated in the ICARE4EU project. The authors are grateful to the programme managers for sharing information on their programmes.

The authors and editors are also grateful to Jan de Maeseneer (Ghent University, Belgium) and Nick Fahy (independent consultant), for reviewing this publication and contributing their expertise.

All rights reserved. NIVEL and TU Berlin have granted the European Observatory on Health Systems and Policies permission for the reproduction of this Policy Brief.

The content of this Policy Brief represents the views of the authors only and is their sole responsibility; it cannot be considered to reflect the views of the European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains.

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What is a Policy Brief?