Impact Assessment of an Innovative Integrated Care Model for Older Complex Patients with Multimorbidity: The CareWell Project
In aging populations, multimorbidity (two or more chronic diseases in the same person) is very common. Patients with multimorbidity have complex health and social needs, are at risk of being admitted to the hospital or residential care home and require a wide range of interventions.
To satisfy the needs of these patients and their families, new innovative integrated care models are needed. To be effective, they should have primary care as the cornerstone of care, effective integration between care levels, empower patient and carers/families, and should be patient-centered. The use of information and communication technology (ICT) platforms could facilitate and improve communication promoting patient empowerment and home support. This innovative interoperability should increase effectiveness, efficiency, and equity.
The aim of the CareWell project was to implement and to assess the effectiveness of an integrated care program based on the coordination between health providers, home-based care, and patient empowerment, supported ...