Action 3 - Collaborative management of complex chronic patients

Aim - The program addresses core aspects of the management of Complex Chronic Patients (CCP) across the healthcare tiers, as illustrated in the figure:
  • ​Implementation of clinical processes resulting in integrated care interventions for two use cases: a) Community-based management of CCP including transitional care and long-term care; and, b) Integrated care for patients under long-term oxygen therapy.
  • Adoption of collaborative and adaptive case management (ACM) (Cano, I. et al., J. Biomed. Inform. 2015 55, 11–22) for the two use cases indicated above.
  • ​Evaluation of the impact of enhanced clinical health risk assessment and stratification (Dueñas-Espin, I. et al., BMJ Open. 2016 15;6(4)).
  • Innovative assessment of healthcare value generation of the services, both during the deployment phase and after regional scale-up of the novel services.
​Background – Proven efficacy of integrated care interventions assessed through randomized controlled trials may not translate into effectiveness at health system level (Hernández, C. et al., NPJ Prim. Care Respir. Med. 2015 25, 15022). In this respect, preparation of the workforce and enhanced clinical stratification have been identified as two key limiting factors for successful deployment of integrated care. Both factors are taken into account in the two target use cases. Moreover, implementation research strategies will be used to assess adoption.