16 components for evaluation
Dear colleagues,
You are kindly asked to respond the questionnaire and evaluate the following multimorbidity care model components to the extent of their implementation available in your national healthcare setting.
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DELIVERY OF THE CARE MODEL SYSTEM
1. Regular comprehensive assessment of patients
Comprehensive assessment is a diagnostic process that should be used to determine medical, psychological, and functional capabilities of patients with multimorbidity in order to develop a coordinated and integrated care plan for multidisciplinary treatment and long-term follow-up of the patients.
Not applicable in my healthcare setting
Very applicable
Comment
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2. Multidisciplinary, coordinated team
A multidisciplinary team aims at increasing efficiency and accessibility of care by providing coordinated multidisciplinary care both in terms of different levels of the healthcare profession (nurses, physicians, physiotherapists, social workers, etc.), and different disease specializations.
Not applicable in my healthcare setting
Very applicable
Comment
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3. Professional, appointed as a coordinator of an individualized care plan and a contact person for a patient and a family (“a case manager”)
A case manager should act as an individualized care plan coordinator who intermediates between a patient and various members of the multidisciplinary team to manage care, actively linking the patient to the providers of medical services, providing residential, social, behavioural, and other support services when needed in the most effective way, monitoring continuity of care, follow-up, and documentation.
Not applicable in my healthcare setting
Very applicable
Comment
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4. Individualized care plans
Individualized, coordinated, and integrated plans for the treatment and long-term follow-up of patients should be developed based on the comprehensive assessment by a multidisciplinary team, including a patient-centred approach that considers preferences of the patients, and prioritization of cross-disease, holistic approach, including targeting symptoms, functional ability, quality of life, desired patient outcomes, etc.
Not applicable in my healthcare setting
Very applicable
Comment
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DECISION SUPPORT
5. Implementation of evidence based practice
Flexible application of disease-specific evidence based guidelines, with consideration of multimorbidity, disease interactions, and drug-drug interactions should be used. Healthcare providers should promote clinical care that is consistent with available scientific evidence and patient preferences.
Not applicable in my healthcare setting
Very applicable
Comment
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6. Training of members of a multidisciplinary team
Training members of a multidisciplinary team aims at improving professional knowledge and skills and focuses on comprehensive assessment concepts, multimorbidity and its consequences, health outcomes, innovation technologies, implementation of individualized treatment/care plans and goal setting, working effectively as a team, training in critical appraisal of knowledge and evidence based knowledge, patient-centeredness, patient empowerment, and self-management.
Not applicable in my healthcare setting
Very applicable
Comment
Your answer
7. Developing a consultation system to be adviced by professional experts
This component encompasses the development of a consultation system to increase accessibility to a very specific professional knowledge. A consultation system aims at providing decision support in situations where further clinical support or knowledge is needed outside of the core team.
Not applicable in my healthcare setting
Very applicable
Comment
Your answer
SELF MANAGEMENT SUPPORT
8. Training of care providers to tailor self-management support based on the patient’s preferences and competencies
Comprehensive training of health care providers should aim at supporting self-management among patients and their caregivers, encouraging patients to increase health literacy, tailored health promotion and prevention strategies.
Not applicable in my healthcare setting
Very applicable
Comment
Your answer
9. Providing options for patients and families to improve their self-management
Provision of options for patients to improve their self-management should be personalized and consistent with their individualized care plans, taking into account their knowledge, educational level, health literacy, and functional aspects. It aims at improving self-management, promoting healthy lifestyles, and encouraging patients to actively participate in decision making, while supporting them in coping with chronic conditions in their daily life. Family members should be included and family education should be encouraged with the consent of the patient.
Not applicable in my healthcare setting
Very applicable
Comment
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10. Shared decision making (a care provider and patients)
Health care professionals should encourage patients (and, where relevant, their families) to actively participate in decision making about their care and treatment, including identification of their individual needs as well as developing of future goals and outcomes.
Not applicable in my healthcare setting
Very applicable
Comment
Your answer
INFORMATION SYSTEMS AND TECHNOLOGY
11. Electronic patient’s records and computerized clinical charts
Electronic patient records and computerized clinical charts should be regarded as an electronic technology used to enter data and manage the care of the patients, to keep track of their medical history, diagnoses, symptoms, hospital visits, health care utilization, care needs or medication, etc., allowing different providers of health and social care to share information about a patient, preferably using standardized tools and similar diagnostic systems.
Not applicable in my healthcare setting
Very applicable
Comment
Your answer
12. Exchange of patient information (with a patient’s permission) between care providers and sectors by compatible clinical information systems
Exchange of patient information (with the consent of the patient) involves different providers of health and social care that share information about a patient between the multimorbidity team and multiple care providers preferably using standardized or compatible tools and similar diagnostic systems.
Not applicable in my healthcare setting
Very applicable
Comment
Your answer
13. Uniform coding of patients’ health problems where possible
Uniform classification system for coding diagnoses and other information related to the patient‘s treatment and care should be used for ensuring continuity of care and sharing of information between nurses, physicians, and other care providers to evaluate and record symptoms, diagnoses, medication, patient-reported outcomes, individualized treatment/care plans, and aspects of health care utilization.
Not applicable in my healthcare setting
Very applicable
Comment
Your answer
14. Patient-operated technology allowing patients to send information to their care providers
Patient-operated technology should allow patients to send health monitoring information to their care providers to complement face to face visits (with the consent of the patient). This should include technology tailored to the patient’s needs which allows health care professionals to view, monitor, and react to information received directly from their patient via the technology aiming to reduce health care utilization and improve clinical outcomes. Potential target populations include patients who live remotely, or those with low social support or with reduced mobility.
Not applicable in my healthcare setting
Very applicable
Comment
Your answer
SOCIAL AND COMMUNITY RESOURCES
15. Supporting access to community- and social-resources
This component enables improvement of the patient‘s access to community resources, formal care, and patient associations, support groups, and psychosocial support (including home help, transportation, etc.), and supports access to such services.
Not applicable in my healthcare setting
Very applicable
Comment
Your answer
16. Involvement of a social network (informal), including friends, patients’ associations, families, neighbours
This component comprises the involvement of the patient’s informal social network, including family, friends, patients’ associations and neighbours within the treatment or care, to increase the social support network.
Not applicable in my healthcare setting
Very applicable
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