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 by ICT-based platforms. The study focuses on the quantitative evaluation of clinical effectiveness, physical functional status, use of health services, and patient’s satisfaction outcomes, although organizational aspects, economic impact and safety have also been evaluated for the overall project.
In Europe, the number of older people with multiple chronic conditions is increasing. New strategies, such as integrated and technology-supported care programs, are needed to address the complex health and social needs of these patients and their carers. The CareWell program is an integrated care approach specifically designed to manage these patients. Its implementation suggested improvements in the use of health services with a shift towards primary care services, some clinical improvements, and a better patient empowerment and understanding.