Protocol for regional implementation of community-based collaborative management of complex chronic patients

Abstract

Over the last few years, the epidemics of noncommunicable diseases and the need for cost-containment1 are triggering factors for a profound transformation of the way we approach delivery of care for chronic patients. In this new scenario, conventional disease-oriented approaches, centered on the management of clinical episodes, are being replaced by patient-centered integrated care services,2 as promoted by the World Health Organization. Lessons learnt from deployment experiences4, 5 following patient-centered approaches are being disseminated as good practices.6 However, there are several factors that need further attention, such as the need for further assessment of implementation strategies in real-world scenarios and the lack of transferability from progress achieved in disease-oriented integrated care to management of complex chronic patients (CCP).5, 7 Likewise, efficacy achieved in integrated care interventions, assessed through randomized controlled trials, may not translate into effectiveness at health system level.

In addition, poor comparability among experiences on management of multimorbidity emerges as an important hurdle for the adoption of integrated care. In this regard, the lack of an operational definition for CCP is not a negligible factor, as it clearly limits an appropriate service workflow design, which, in turn, precludes both evaluation and comparability of reported experiences.