Tilburg University
The SELFIE framework for integrated care for multi-morbidity
Leijten, F.R.M.; struckmann, V.; van Ginneken, E.; Czypionka, T.; Kraus, M.; Reiss, M.;
Tsiachristas, A.; Boland, M.; de Bont, A.A.; Bal, R.A.; van Molken, M.P.M.H.
Published in:
Health Policy
DOI:
10.1016/j.healthpol.2017.06.002
Publication date:
2018
Document Version
Publisher's PDF, also known as Version of record
Link to publication in Tilburg University Research Portal
Citation for published version (APA):
Leijten, F. R. M., struckmann, V., van Ginneken, E., Czypionka, T., Kraus, M., Reiss, M., Tsiachristas, A.,
Boland, M., de Bont, A. A., Bal, R. A., & van Molken, M. P. M. H. (2018). The SELFIE framework for integrated
care for multi-morbidity: Development and description. Health Policy, 122, 12-22.
https://doi.org/10.1016/j.healthpol.2017.06.002
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ContentslistsavailableatScienceDirect
Health
Policy
jo u rn al h om ep a ge :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l
The
SELFIE
framework
for
integrated
care
for
multi-morbidity:
Development
and
description
Fenna
R.M.
Leijten
a,∗,1,
Verena
Struckmann
b,1,
Ewout
van
Ginneken
c,
Thomas
Czypionka
d,
Markus
Kraus
d,
Miriam
Reiss
d,
Apostolos
Tsiachristas
a,e,
Melinde
Boland
a,
Antoinette
de
Bont
a,
Roland
Bal
a,
Reinhard
Busse
b,
Maureen
Rutten-van
Mölken
a,f,
on
behalf
of
the
SELFIE
consortium
aInstituteofHealthPolicyandManagement,ErasmusUniversityRotterdam,theNetherlands bDepartmentofHealthCareManagement,BerlinUniversityofTechnology,Germany
cEuropeanObservatoryonHealthSystemsandPolicies,BerlinUniversityofTechnology,DepartmentofHealthCareManagement,Germany dInstituteforAdvancedStudies,Vienna,Austria
eHealthEconomicsResearchCentre,UniversityofOxford,UK
fInstituteforMedicalTechnologyAssessment,ErasmusUniversityRotterdam,theNetherlands
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:Received20September2016 Receivedinrevisedform31May2017 Accepted12June2017 Keywords: Integratedcare Multi-morbidity Framework Conceptual Model Frailelderly Chroniccare Comorbidity
a
b
s
t
r
a
c
t
Background:Theriseofmulti-morbidityconstitutesaseriouschallengeinhealthandsocialcare organi-sationthatrequiresashiftfromdisease-towardsperson-centredintegratedcare.Theaimofthecurrent studywastodevelopaconceptualframeworkthatcanaidthedevelopment,implementation,description, andevaluationofintegratedcareprogrammesformulti-morbidity.
Methods:Ascopingreviewandexpertdiscussionswereusedtoidentifyandstructureconceptsfor integratedcareformulti-morbidity.Asearchofscientificandgreyliteraturewasconducted.
Discussion:meetingswereorganisedwithintheSELFIEresearchprojectwithrepresentativesoffive stakeholdergroups(5Ps):patients,partners,professionals,payers,andpolicymakers.
Results:Inthescientificliterature11,641publicationswereidentified,92wereincludedfordata extrac-tion.AdraftframeworkwasconstructedthatwasadaptedafterdiscussionwithSELFIEpartnersfrom8EU countriesand5Prepresentatives.Thecoreoftheframeworkistheholisticunderstandingoftheperson withmulti-morbidityinhisorherenvironment.Aroundthecore,conceptsweregroupedintoadapted WHOcomponentsofhealthsystems:servicedelivery,leadership&governance,workforce,financing, technologies&medicalproducts,andinformation&research.Withineachcomponentmicro,meso,and macrolevelsaredistinguished.
Conclusion:Theframeworkstructuresrelevantconceptsinintegratedcareformulti-morbidityandcan beappliedbydifferentstakeholderstoguidedevelopment,implementation,description,andevaluation. ©2017TheAuthors.PublishedbyElsevierIrelandLtd.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
AsWestern populationsareageing,theprevalenceof multi-morbidityisrapidlyincreasing.Personswithmulti-morbidity,as comparedtopersonswithasinglechronicdisease,havealower quality of life [1], a higher age-adjusted mortality [2], greater healthcareutilizationsuchasagreaterlikelihoodtobeadmittedto hospitalandlongerlengthofhospitalstay[3],greaterabsenteeism
∗ Correspondingauthor.
E-mailaddress:leijten@bmg.eur.nl(F.R.M.Leijten).
1 Sharedfirst-author:theseauthorscontributedequallytothispublication.
[4]andearlierexitfromtheworkforce[5].Althoughmethodsto measuremulti-morbiditydiffergreatlybetweenstudiesand coun-tries,theprevalenceinthepopulationover65yearsiscommonly estimatedtobelargerthan60%[6–9].Multi-morbidity,however, isnotsolelyaconcernamongstolderpersons,asinabsoluteterms therearemoreyoungerpersonswithmulti-morbidity[7].
Inthecurrentarticlemulti-morbidityisdefinedasmultiple(i.e., atleasttwo)chronicconditions,physicalormental,occurringin onepersonatthesametime,whereoneisnotaknown compli-cation oftheother.Persons withmulti-morbidityoftenrequire carefrommultipleprofessionalswithinthehealthcare-andsocial caresectors. In afragmentedcare system,thiscreates conflict-ing, overly-demanding, treatment advices that may discourage
https://doi.org/10.1016/j.healthpol.2017.06.002
Box1:AbouttheSELFIEproject.
SELFIE (Sustainable intEgrated chronic care modeLs for multi-morbidity:delivery, FInancing, and performancE) is a Horizon2020 funded EU project that aims to contribute to the improvement of person-centred care for persons with multi-morbidityby proposingevidence-based,economically sustainable,integratedcareprogrammesthatstimulate coop-erationacrosshealthand socialcareand aresupported by appropriatefinancing and payment schemes.More specifi-cally,SELFIEaimsto:
• Develop a taxonomy of promising integrated care pro-grammesforpersonswithmulti-morbidity;
• Provide evidence-based advice on matching financ-ing/payment schemes with adequate incentives to implementintegratedcare;
• Provideempiricalevidenceoftheimpactofpromising inte-gratedcareonawiderangeofoutcomesusingMulti-Criteria DecisionAnalysis;
• Developimplementationand changestrategiestailoredto differentcaresettingsandcontextsinEurope,especially Cen-tralandEasternEurope.
The SELFIE consortium includes eightorganisations in the following countries: the Netherlands (coordinator), Austria, Croatia,Germany,Hungary,Norway,Spain,andtheUK.www. selfie2020.eu[GrantAgreementNo634288].
compliance.Thuspersonswithmulti-morbidity,arelikelyto ben-efitfromintegratedcarethatiswellcoordinatedandcontinuous
[10]. In thecurrent article integrated care is defined as struc-turedeffortstoprovidecoordinated,pro-active,person-centred, multidisciplinarycarebytwo ormorewell-communicatingand collaboratingcareproviderseitherwithinoracrosssectors.Inorder torealizesuchintegratedcare,aparadigmshiftfromdisease-to person-centerednessisnecessaryinservicedelivery,management, andfunding[11].
Evidence on the effectiveness of integrated care for multi-morbidityisstilllimited[12–15].Nonetheless,variousinnovative programmeshavebeenidentifiedinwhichintegratedcareisbeing provided for persons with multi-morbidity (Struckmann et al., submitted)[10].Theseprogrammesvarygreatlywithregardto targetgroup,involvedcareproviders,implementationpractices, andactualcaredelivery.Inordertobeabletocompareintegrated careprogrammesformulti-morbidityindifferentcontextsitwould behelpfultoapplyageneralframeworkthatstructuresrelevant concepts.Currently,integratedcareprogrammesoftenreferto ele-mentsofWagner’sChronicCareModel[16].Thismodel,however, wasnotmadespecificallyformulti-morbiditycare.Inthecaseof multi-morbidity,specific issuesneed toreceivemore attention, suchasdealingwithmultiplecareproviderspotentiallyworkingin differentsectors,theriskofcarefragmentation,paymentformsthat adequatelyaccountformulti-morbidity,treatmentinteraction,the needtoprioritisetreatmentsgoals,andtheapplicabilityofsingle diseaseguidelines.
Theaimof thisstudy istodevelop a conceptualframework thatcanbeusedtoaidthedevelopment,implementation, descrip-tion,andevaluationofintegratedcareformulti-morbidity.Itcan beusedbydifferenttypesofactorsinthefield,e.g.developersof integratedcareprogrammes(clinicians,managers),policymakers, healthinsurers,andresearchers.
Thenecessityforsuchaframeworkwasacknowledgedbythe EuropeanCommission,whichgrantedHorizon2020fundstothe SELFIEresearchproject(seeBox 1).Thedevelopmentofa con-ceptualframeworkforintegratedcareformulti-morbidityforms partoftheinitialworkbeingconductedintheSELFIEproject.The
frameworkwillbeusedtoguidethedescriptionandevaluationof promisingintegratedcareprogrammesformulti-morbidityinthe eightSELFIEpartnercountries.
2. Methods
Ascopingreviewofscientificandgreyliteratureandexpert dis-cussionswereusedtoidentifyandstructurerelevantconceptsof integratedcareforpersonswithmulti-morbidityintoaframework. Ascopingreviewwaschosenasanapproachtoreviewdifferent aspectsrelatedtointegratedcareformulti-morbidityinthe sci-entificandgreyliterature,asthestrengthofthismethodliesin producingbroadandcomprehensiveresults[17].Discussionswith expertswereusedtocomplementthefindingsfromtheliterature andtoensurethattheconceptsandstructureoftheframework wererecognized,understood,andcouldbeusedinthefuture. 2.1. Scopingreview
AsearchforscientificliteraturewasconductedinOctober2015 inthefollowingelectronicdatabases:Cochrane,Embase,PubMed, PsycInfo,Scopus,SociologicalAbstracts,SocialServicesAbstracts, andWebofScience.Articlesweresearchedforthatpertainedto1) models(e.g.,concepts,frameworks,theories),2)integratedchronic care(e.g.,comprehensivecare,managedcare,collaborativecare), and3)multi-morbidity(e.g.,multiplehealthproblems, comorbid-ity,frailelderly).Acomprehensivesearchstrategywasdeveloped withtheassistanceofalibrarian.Whenpossiblestandardizedor indexedsearchtermswereused.Thefollowingin-andexclusion criteriawereused:
• Inclusioncriteria:amodel(i.e.,framework,theory)orkey ele-mentsofintegratedcareformulti-morbidityisdescribed • Exclusioncriteria:single-diseasefocus,fundamentalbiomedical
studies,conferenceabstracts,letterstotheeditor,editorials,or commentaries,nofulltextavailable,non-Englishlanguage.
Reviewing wasdonein two steps, firston thebasis of title andabstract,andhereafteronfulltext.Bothstepsweredoneby twoindependentreviewers.Hereafter,datawasextractedbysix reviewersworkinginpairson:publicationdetails,methods,key conceptspertainingtointegratedcare.Dataextractionwasdone duringthewinterof2015–2016.Moredetailsonthemethodsof thescopingreviewofthescientificliteratureincludingthesearch termsandaflowchartofin-andexcludedpublicationscanbefound inStruckmannetal.(submitted).
Alongside the scoping review of the scientific literature, a targetedsearchwasconductedinthe[grey]literature.Key publica-tionswereidentifiedthatwererelatedtointegratedcareingeneral ortospecificthemesintheframework.Furthermore,specific multi-morbidityreports,andfindingsfromrelatedresearchprojectswere included.
2.2. Expertdiscussionmeetings
AdraftframeworkmadebythecoregroupofSELFIEresearchers waspresented inJanuary 2016tomembers of theSELFIE con-sortiumandtheSELFIEinternationalstakeholderadvisoryboard. Representatives of the SELFIE consortium are from academic institutionsin the eight SELFIE partner countries. The interna-tionalstakeholderadvisoryboardismadeupofrepresentatives fromfivestakeholder groups(5Ps):Patients(e.g.,patientforum representatives, persons with multi-morbidity), Partners (e.g., informal caregivernetwork representatives), Professionals(e.g., medical doctors, researchers, and experts in the field of inte-grated care/multi-morbidity), Payers (e.g., persons working for healthinsurers), and Policymakers (e.g.,personsfrom interna-tionalhealthpolicyorganisationsandguidelinenetworks).These expertsprovidedfeedbackontheframeworkfromtheirdifferent cultural,political,healthsystem,professional,andpersonal per-spectives.Aftertheinternationalmeeting,thecoregroupofSELFIE researchersheldseveralmorebrainstormsessionstousethis feed-backtocreate a revisedversion ofthe framework. Meanwhile, findingsfromthescopingreviewreceivedastrongerpresencein theframeworkandthedescriptionthereof.
A revised framework was developed that encompassed the micro,meso,andmacrolevelsandgroupedconceptsintosix com-ponents: service delivery, leadership & governance, workforce, financing, technologies &medical products, and information & research.Thesecomponents stem fromtheWHO six key com-ponents used to describe, understand, and compare different healthsystems(i.e.,leadershipandgovernance,healthinformation systems,healthfinancing,humanresourcesforhealth, essential medicalproductsandtechnologies,andservicedelivery)[18].The componentswereslightlyadaptedfortheSELFIEframeworktobe applicableforintegratedcareformulti-morbidity.Theuseofthese familiarandwell-definedcomponentswillfacilitatetheuseofthe frameworkindifferentcontexts.
Inthespring-summerof2016,nationalstakeholdermeetings withrepresentativesfromthe5PswereheldinallSELFIEpartner countries.Duringthesenationalmeetings,therevisedframework waspresentedanddiscussed.SELFIEpartnersreturnedfeedback fromtheirmeetingstothecoregroupofSELFIEresearcherswho usedthistofurtherdeveloptheframework.
Theframeworkpresentedinthisarticlethuscomesforthfrom aniterativeprocess−findingsfromthescopingreviewandthe expertmeetingswereusedtocontinuouslyupdateandoptimize theframework.
Themethodsusedtodeveloptheframeworkareofaqualitative nature.Conceptswereclusteredanddescribedthatarelikelyto berelevantintheprovisionofintegratedcareformulti-morbidity, however,noweightorsystematiccomparisonbetweenthe rele-vanceofconceptshasbeenmade.
3. Results
3.1. Scopingreview
Thesearch in thescientific literature yielded11,641 unique publications.Afterreviewingtitlesandabstracts,270publications remained.Afterfulltextreviewing,92publicationswereincluded inthisstudyforthepurposeoftheframeworkdevelopment.
Mostofthearticlesincluded(78%)wereofadescriptivenature −describingfocusgroupandinterviewstudies,andstudydesigns ofintegratedcareprogrammesformulti-morbidity.Asthesearch strategywasquitebroadwithregardto‘multi-morbidity’,studies wereincludedonspecificmulti-morbidcombinationsbutalsoon moregeneralcomplexpatientsandfrailelderly(including pallia-tivecarestudies)inwhichthemajorityconsistsofpersonswith multi-morbidity.Thefullresultsofthescopingreviewofthe
sci-entificliteratureareextensivelydescribedelsewhere(Struckmann etal.,submitted).
Theadditionaltargetedsearchforrelevant[grey]literatureled totheinclusionofscientific literaturepertaining totheChronic CareModel[16],theGuidedCareModel[19],andtheDevelopment ModelforIntegratedCare[20,21].Additionalscientificliterature specificallyonfinancingwasincluded,asoursearchstrategydid notcapturethisthemeentirelybutitwasdeemedasimportant fortheframeworkdevelopment[22–28].Thisliteraturewas iden-tifiedthrough asearch for specificjournalsandexpertsknown topublishinthisfieldandthroughdiscussionwithproject part-nersandstakeholders.TheCochranereviewsonindividualisedcare planningandshareddecision-makingwerealsoincluded[29,30]. Furthermore,theWHO‘WorldReportonAgeingandHealth’[31]
and‘Globalstrategyonpeople-centredandintegratedhealth ser-vices’[11]wereused,aswellasareportpublishedbytheKing’s Fundon ‘Providingintegrated care for older peoplewith com-plexneeds’[32].ResultsfrompriorEU-fundedprojectswereused: ‘ICARE4EU’,whichaimstocompareintegratedcareprogrammes formulti-morbidity[10,33–36],theJointActiononChronic Dis-eases(JA-CHRODIS),specificallyresultsfrom theworkfocusing onmulti-morbidity [37], and ‘Advanced CareCoordination and TeleHealthDeployment’(ACT)[38].In ordertogaininsightinto guidelinesformulti-morbidity,theUKNICEdraftguideline was usedasitisextensiveandthemostrecent[39].
3.2. TheSELFIEframeworkforintegratedcareformulti-morbidity TheconceptualframeworkispresentedinFig.1.Theframework iscomprisedofacoreinwhichtheindividualwithmulti-morbidity and his or her environment is placed centrally. Concepts per-tainingtointegratedcareformulti-morbidityaregroupedatthe micro,mesoandmacrolevels.Theyarefurthersplitaccordingto thesix[WHO]components:servicedelivery,leadership& gover-nance,workforce,financing,technologies&medicalproducts,and information&research.Below,firstthecoreoftheframeworkis described,where aftereach component,startingat thetopand movingclockwise,isdescribedatthemicro,meso,andmacrolevel. Lastly,theroleofmonitoringisdescribed.
3.2.1. Holisticunderstandingoftheindividualwith multi-morbidityinhis/herenvironment
The basis of person-centred integrated care for individuals withmulti-morbidityisaholisticunderstandingofthese individu-als’healthandwell-being,capabilities,self-managementabilities, needs,preferences,andtheenvironmentthattheyfindthemselves in.e.g.[31,40,41].Oftenaholisticunderstandingofanindividual withmulti-morbidityandhisorherenvironmentisaidedbyformal assessments[19,31,32,37,39,42–51,60,67,73].However,theword understandingisusedintheframeworkinsteadofassessmentin ordertosignifythatanindividual’ssituationisdynamic,notstatic, andthusrequiresregularmonitoring.
Fig.1.TheSELFIEFrameworkforIntegratedCareforMulti-Morbidity.
alwaysbedonetakinganindividuals’capabilitiesandpreferences intoconsiderationandadapting[self-management]expectations accordingly. To this end, elements entangled in an individual’s preferencesshouldalsobeunderstood,suchastheirpersonality, religion,culture,ethnicity,illnessperceptions,socio-financial posi-tion,andeducationalbackground.
A holistic understanding includes the individual’s environ-ment[31].Environmentalelementsplayaroleintherelationship betweentheindividual’ssituationand theprocessofintegrated care.Thesocialnetworkisanimportantelementtoconsider,such astheavailabilityoffamilymembers,friends,andneighbourswho canbeinvolvedasinformalcaregivers,aswellastheburdenof carethattheinformalcaregiversmayexperience[31,39,57,67–70]. Otherenvironmentalelementstoconsiderinclude:financial situa-tion(e.g.,issomeonefinanciallyindependent?)[60,71,72],housing (e.g.,doessomeonelivealone,arethebed-andbathroomonthe groundfloor?)[73],thephysicalsurroundings(e.g.isitsafe, prox-imity toservices?),theavailability of communityservices (e.g., self-helpgroups)[16,62,74],andtransport(e.g.,isaccessiblepublic transportavailable,parkingcosts?)[19,73,75].
3.2.2. Servicedelivery 3.2.2.1. Micro.
Aspersonswithmulti-morbidityneedtodealwithmultiplehealth and/orsocialproblems,itisespeciallyimportanttooffera person-centredintegratedcareapproachthatistailoredtotheindividual and his or her environment [21,39,56,66,68,76]. Tailoring care can be done on the basis of a formal holistic assessment, as describedintheprevioussection.Asthesituationofpersonswith multi-morbidity may change over time, flexibility is important
[64,68,77,78]−flexiblecarecanbecontinuouslyupdatedtomatch aperson’sneeds[79,80,104].
monitoringtodetectsignsofprogressionandpotential complica-tionsinanearlyphase[50,56,88].Personswithmulti-morbidity may find self-management very demanding, so education and coaching need to be tailored toan individual’s ‘starting point’
[21,63,89].
Aspersonswithmulti-morbidityoftendealwithdifferent pro-fessionals,organisations, and sectors, it is important toensure smooth and monitoredtransitions throughout thecare process
[11,16,19,68,90,91].Variousintegratedcareprogrammespointto continuity as a critical element [43,44,75] that facilitates good relationship-buildingbetweenpersonswithmulti-morbidity, pro-fessionals,andinformalcaregivers[56,92].
Whenever possible, involving the informal caregiver in the decision-making process is desired [64,71,85,93], especially in multi-morbidity[37,65,87].Theinformalcaregivercanbeinvolved inoverallcareplanning[19,86],insettingpriorities[94],and dur-ingtransitionsbetweensites(e.g.,afterhospitaldischarge)[84]. However,theinformalcaregiver’sneeds[56,95],qualityoflife,and burdenofcaregivingshouldbeconsideredastheymayhavehealth problemsthemselvesandbebalancingacareeraswell[75,96].
For persons with multi-morbidity that take multiple medi-cations,prescribed bymultiple care providers[78],medication adherence, accumulation of side-effects, and drug-interactions maybecomeanissue[10].Becausetheevidenceinguidelinesis oftenbasedonstudiesinpatientswithasingledisease[78,97], try-ingtofollowmultiplesingle-diseaseguidelinessimultaneouslyhas beencritiqued[78,87].Hence,attentionisrequiredfortreatment interactions(i.e.,polypharmacy[72,78,84]andguideline interac-tions[64,78,79]).Careprovidersmayneedtheflexibilitytotailor disease-specific guidelines [65,84,98]. However, providers may lacktrainingtodoso[99].Forthisreason,person-centred guide-linesformulti-morbidityarebeingdeveloped,suchasthoseby NICE[16,39,69,100].Animportantelementoftheseguidelinesis thereviewofmedicationsandtreatmentsandtheirinteractions
[39,81,101],includingadiscussionabouttherelevanceofcertain medicationsprescribedwithalong-termpreventionperspective forpeoplewithalimitedlifeexpectancy[39].
3.2.2.2. Meso.
Organisationalandstructuralintegrationcanfacilitateintegrated caredeliveryand especiallyincrease sustainability[102].Inthe care provision of multi-morbidity this may be especially rele-vant,asintegrationacrosshealth-andsocialcaresectorsmaybe needed.Differenttypesoforganisationalstructuresarepossible, rangingfromfullyintegratedformalalliancesormergersto infor-malcooperationagreements[32,71].Theneedfororganisational transparencyand ongoing communication toensure integrated carehavebeenhighlighted[103,104],aswellastheneedforhealth, social,andcommunityservicestobelinked[16].Itisimportantto notethatanintegratedorganisationdoesnotnecessarilymeanthat caredeliverywillbeintegrated[56],norisorganisational integra-tionagoalinitself−itisameansofimprovingandintegrating care[32].Ithasbeenproposedthatincreatingcollaborativeand integratedcare,thisshouldbe‘structuredforflexibility’,meaning thatsystemsinplaceaprioriexpecttheunexpectedandareready andabletotrulypersonalizecare[104].
Persons with multiple chronic conditions pose a challenge foreffectivecontinuousqualityimprovementsystems,ascurrent qualitystandardsmostlyaddresssingle-diseases[65].Identifying anddevelopingindicatorsinmulti-morbidityisachallenge[105]. 3.2.2.3. Macro.
Integrated care programmes for multi-morbidity would bene-fit from macro level policies that stimulate the integration of careacrossorganisationsandsectors,suchasthroughcloselinks betweenMinistriesofHealthandofSocialAffairs[106].In
par-allel,in competitiveenvironments,market regulationisneeded thatallowsforcollaborationbetweenprovidersbutprotects con-sumerchoice,suchasmoreflexibleanti-trustlaws.Lastly,policies that ensureservice availability and access needto bein place. Thispertainstotheavailabilityofcommunityandpublichealth resourcesandtimely(e.g.,acceptablewaitingtimes),geographical (e.g.,reasonabletraveltimes)andphysical(e.g.,wheelchair acces-sible)access.Serviceaccessshouldprotectvulnerablegroups,such asthosewithmulti-morbidity.
3.2.3. Leadership&governance 3.2.3.1. Micro.
Inthecaseofmulti-morbidity,prioritisationisakeyaspect,but dis-crepancieshereincanexistbetweenpersonsinvolvedinthecare process[78,84].Shareddecision-makingisthusanintegralpartof integratedcare,andentailsdiscussinggoalsandoptionstoachieve these, identifying and clarifying issues and possible solutions, and ensuringthat allinvolved personsunderstandone-another
[21,30,37,39,41,62,66,69]. The personwith multi-morbidity and the informal caregiver should be empowered and engaged in becomingpartners[11,16,41,70,93,104]withsharedresponsibility
[38,56]inthedecision-makingandcareprocess.Thegoalhereofis maintainingautonomy,increasingadherence,andimproving out-comes[38,41,104].
Shared decision-making should result in the develop-ment of a single individualised care plan [45]. For persons with multi-morbidity individualised care planning appears to promise more successful integrated care [19,29,32,39,43]. Planning may include agreed upon goals and treatments, timelines, responsibilities, and follow-up to review progress.
[38,44,46,49–51,66,71,72,74,77,81,84,94,96,104]Planscanalsobe usedtoreassessandadjustgoals,ensurecontinuityofcare,and actasacommunicationtoolbetweenprovidersandpatients[45].
Such plans should also specify who is responsible for the coordinationofcare.Coordinationshouldbetailoredtothe com-plexity of the person’s care needs [103]. In managingpersons withmulti-morbidity, recognitionis needed that not everyone requiresthemostintenseformofcoordination(e.g.,acase man-ager)[80,99,107].Aformalholisticassessmentcanbeusedasa meansof determiningthetype ofcareneeded[70]andtohelp staffdeterminewhichresources(e.g.,thelevelofcoordination)are needed[48].
3.2.3.2. Meso.
Successful implementation of integrated care for multi-morbid personscanbestimulatedbysupportiveleadershipthatisfully committedtoclearly-definedgoals,istrustedbythoseinvolved, andacknowledgesprofessionalautonomy[62].Supportive lead-ership throughout all levels of integrated care that promotes opendiscussionisseenasanimportantsuccessfactorfor inter-professionalcollaboration[103]andcommitmenttoquality[74]. Inlinewiththis,strongandengagedleadersshouldpromotethe uptake of a newapproach and facilitate [readinessfor]change
[16,20,111].Organisationaltransparencyandclearaccountability
towardsemployees(e.g.,careproviders)andend-receivers(e.g., personswithmulti-morbidity,informalcaregivers)areimportant tofosterindecision-makingprocesses[11].
Furthermore,inprovidingintegratedcareformulti-morbidity itmaybeimportantthatacultureofsharedvision,ambition,and valuesiscreated[77].Inorderforprofessionalsandorganisationsto successfullycollaborate,willingnessandbeliefinthecollaboration, trustinone-another,andmutualrespectisnecessary[103].
manage-mentshouldbedonecarefullytoavoidopportunisticbehaviour, butinsteadcreateacultureofcontinuousimprovement.Thiscan befacilitatedbyacontinuousqualityimprovementsystem. 3.2.3.3. Macro.
A person-centred integrated care programme can benefit from widerpoliticalcommitmentandshouldbewell-embeddedinthe structureandgovernanceoftheregionalandnationalsystem,as thesecanbothpositivelyandnegativelyinfluenceaprogramme
[102].Thusitisimportantthat(inter)national/regionalpolicyand actionplansonchronicdiseasesandmulti-morbiditypromote mul-tidisciplinaryandinter-organisationalcollaborativecare[11]. 3.2.4. Workforce
3.2.4.1. Micro.
Integratedcareformulti-morbiditycallsformultidisciplinaryteam workthatcrossesthehealthcare,socialcare,andvolunteerwork boundaries[12,16,21,31,32,37,41,44,68,71,73,82,85,94]. Multidis-ciplinaryteamsneedtobetailoredtothetargetpopulationand thecontext[71],anditisimportanttorealizethatittakestimeto achieveeffectiveteamwork[108].Notonlyprofessionalswith dif-ferentbackgroundsneedtoworktogetherandtrustone-another, but also personswith multi-morbidity and informal caregivers themselvesneedtobeinvolvedinsuchteams[80].Animportant aspectofefficientteamworkisgoodcommunicationbetweenall personsinvolvedintheprocess[48,85,99].
Often,adifferentiationismadebetweenacoregroupof pro-fessionals and a wider network that can be called upon [32]. Havingtoomanyprofessionalsinvolvedinthecoreteamcan con-fuseandoverwhelmpersonswithmulti-morbidityanddiscourage them from taking onan active role in the care process them-selves[63].Clearrolesandresponsibilitiesforallpersonsinvolved, includingthe person withmulti-morbidity him- orherself, are thusdesirable.Havinganamedcoordinatorisdeemedimportant
[32,37,38,58,74,76,78,99,102]. 3.2.4.2. Meso.
Continuousprofessionaleducationanddevelopmentisan impor-tanttopicinintegratedcareformulti-morbidity[19,50,64],that canbedividedinto training of‘soft skills’(i.e.,communication, teamworkandrelationships,self-managementpromotion, willing-nesstochange/learn)and managerialskillsformulti-morbidity. Thereseemstobeaneedtotrainskillsinteamworkandin build-ingdurablerelationshipswithpatients, otherprofessionals,and informalcaregivers[58,78,109].Professionalsalsoneedtoknow howtotrain self-managementskills [37,41,82],and specifically learnmotivationalinterviewingtechniques[74,85,96].Managerial skillsincludetraininginbeingacasemanager[49,110],conducting assessments[47,48],navigatingthehealth-andsocialcaresystems
[48],workingwithindividualisedcareplans[48],andknowinghow torisk-stratifyinordertoensurethatcareistailoredto complex-ity[48].Continuousprofessionaleducationanddevelopmentis, however,notself-evidentandstressestheneedforwillingnessto change,learnfromeachother,andtosharebestpractices[21,79]. Asdescribedinthesectionsabove,theroleoftheinformal care-giverinthemulti-morbiditycareprocessisoftenprominent.As botha userandprovider ofcare,theinformalcaregivercanbe foundatthecoreoftheframeworkaswellasinservicedelivery andintheworkforcecomponentsofthecareprocess.However, itshouldalwaysbediscussedopenlywhetherandhowthe infor-malcaregivercanbeinvolvedinthecareprocess.Thecaregiver burdenshouldbeaddressed[10,75]aswellasappropriatesupport forinformalcaregivers[75].Formsofsupportincludeeducation
[19,31]toincreaseabilities [95]andstrengthen confidence[95]
andreducingthepressureofbeingthesoleresponsibleperson(i.e.,
establishingclearresponsibilities,offeringpossibilitiestotakea caregivingbreak).
Appropriateworkforceplanningatorganisationallevelis nec-essary and includesattention forworkload and sufficient team resources[71,104,111],professionaleducation,andsustainability ofstaffandinformalcaregivers[111].Theincreasingpressureon thetraditionalworkforceandtheneedtocontaincostsunderline theneedforexploringnewprofessionalroles(e.g.,physician assis-tants,specialisednursepractitioners,socialdistrictsupportteams)
[27]orshiftingtaskstospeciallytrainedprofessionals,provided thatitisintheinterestofpersonswithmulti-morbidity.
3.2.4.3. Macro.
Atthemacrolevel,workforcedevelopmentmustmatchthe chal-lengesofanageingsocietyinwhichretirementagesareincreasing whileatthesametimeagreaterproportionofpeoplerequirecare formultiplemorbidities.Thesechangesresultinanincreasedneed forcareprofessionals,personswithmulti-morbidity,andinformal caregiversaliketoremaininpaidemploymentlonger.Itis impor-tant toconsiderpossible strainsontheworkforce-demography match.Theworkforceneedstobesustainableinprovidingcare, andlegislationneedstobeinplacethatsupportsflexibleworking arrangements,forexampletoallowinformalcaregiverstobalance paidemploymentandcaregiving[31].
Ineducationalandworkforceplanning,changesindemography andthetypeofcareprovisionthatwillbeneededinthefuture shouldbeconsidered.Forthepriorthiscouldbebyincludingthe trainingofgeriatricskills,generalistcompetencies,and commu-nicationandteamworkskillsincurriculums[31].Forthelatterit canincludeenrollingsufficientstudentsintothesecurriculumsand creatingnewprofessionalrolesandvolunteeropportunities. 3.2.5. Financing
3.2.5.1. Micro.
Coverage and reimbursement of the interventions included in person-centredintegratedcareprogrammesneedtobegenerous enoughtoensureequity infinancialaccessfor thosewhoneed them. Reimbursementstructuresshouldalso guarantee enough timeforprofessionalstoworkwithpersonswithmulti-morbidity and informal caregivers [64]. The extent of co-payments, co-insurance,anddeductibles(cost-sharing)forservicesand goods covered,directpaymentsforthosenotcovered,andinsome con-textsinformalpaymentsshouldalsobeconsideredbecausethese out-of-pocketcostsmayinfluenceaccess,[non]adherence,andhow andwhichcareisused.Certainfinancialincentivesmaybeusedto motivatepersonswithmulti-morbiditytoparticipateinandadhere tointegratedcareprogrammes,suchas,vouchers,freegym mem-berships,freeworkshopsortrainingandoutofoffice-hoursaccess tocare[35].
3.2.5.2. Meso.
Whereas the most dominant payment systems for individual providers arefee-for-service and/or capitation,single organisa-tionsare often paidby Diagnostic RelatedGroups (DRG) oran overall budget. These paymentsystems lack specific incentives to stimulate multidisciplinary collaboration. In fact, the incen-tiveinafee-for-servicesystemistoincreaseproduction;aDRG systemprovidesstrongerincentivesforproducingDRGsthanfor appropriatelyaddressingpatient’sneedswithintheDRG[33].In reaction,newpaymentsystemsthatintendtosupport collabora-tionbetweenprofessionalsandorganisationshavebeenintroduced
toaparticulardiseaseorepisodeduringadefinedperiodoftime
[28].In theNetherlands bundledpayment for thecarefor frail elderly,coveringcareprovidedbyvariousdisciplines(GP, geriatri-cian,occupationaltherapist,pharmacist)isbeingpiloted[112].The mostcomprehensiveformtodatearepopulation-basedpayment frameworksinvolvingthedefinitionofavirtualbudgetthatisbased onthecasemixofthecatchmentpopulation.Whentheactualcosts ofthistargetpopulationarelowerthantheexpectedcosts,based oneitherhistoricaldataornorm-costs,thesavingscanbeshared betweenprofessionalsandorganisationsinvolved.Anexampleof asharedsavingscontractappliedinapopulation-basedintegrated careapproachisthatofGesundesKinzigtalinGermany[113].
Severalblended paymentsystems canbeidentified that are complementedwithpay-for-performancefinancialincentivesto improvequalityofcareandcontrolcosts.Thereisevidencethat thesuccessofsucharrangementsdependsonthedetails,suchas thechoiceofqualityindicators,thedefinitionofthetargets (abso-lute,relative,mixed),thesizeofthebonusorperhapsthepenalty, andthereceiverofthebonus/penalty(theindividualprovideror groupofproviders/organisation)[23,24].
Toavoid providersrunninghigherrisks fortreating persons withmulti-morbidity,itisofgreatimportancethatthereis ade-quate adjustment for differences in case-mix − this may also reduceadverseselectionandcream-skimming.Suchrisk adjust-mentisparticularlyrelevantforpaymentsystemsbasedonpatient or population characteristics like capitation, bundled payment, andpopulation-basedpayments[33].Withoutadequatecase-mix adjustmentinintegratedcare,especiallyforpersonswith multi-morbidity,thereisthepotentialof‘upcoding’,thatmightallowa providertospendmoretimeandresourcesonsuchcomplexcases. Thisisimportant toconsider andunderlines theimportanceof appropriatemonitoringanddatacollection.
Ithasbeenarguedthatabasicleveloffinancialsecurity(‘secured budget’)forproviderorganisationsisnecessarytoensurea sus-tainablecommitmenttoprovidingperson-centredintegratedcare forpersonswithmulti-morbidity[33,36].Thismayrequire longer-termcontracting.Partofthisistherecognitionthatnotonlythe costsof routine delivery of integrated care should be covered, butalsothecostsofdevelopmentandimplementation. Ithelps ifthereisaclearbusiness-caseforeachproviderthataccountsfor economiesofscaleandscope[22].
3.2.5.3. Macro.
Thespecificproviderpaymentsystemsdiscussedaboveare embed-ded in a national or regional financial system for health and social care. Governmental recognitionthat innovative payment systems can be developed specifically to stimulate integrated careis important,becausethat maystimulate more systematic development,research, and evaluation of such systems. When distributing scarce resources at macro-level, governments can decidetoprioritisedevelopmentsthatbenefitintegratedcarefor multi-morbidity,includinganincreasedfocusonpreventionand communityresources[11,31,87].Ensuringequalaccessand safe-guardingequityisamacro-levelresponsibilitythatcanbetaken upbygenerouscoverageand specificactionplanstoreachout toindividualsfromlowersocio-economicclasseswhosufferfrom moremorbiditiesbutmaybemoredifficulttoreach.Furthermore, stimulatinginvestmentsininnovativecaremodels,suchasthose spanningacrosshealth-andsocialcareorstart-upfunding’s,may beneededatanationalorregionallevel.
3.2.6. Technologies&medicalproducts
Thiscomponentiscloselytiedtothe‘Information&research’ component.Thedifferenceisthatthecurrentcomponentstresses theneedfor technologies&medical productstobe developed, user-friendly,andavailabletosupportcare processes.Thenext
component(Information&research)stressesusingthecollected information successfully in the care process, and conducting research.
3.2.6.1. Micro.
Informationandcommunicationstechnology(ICT)canbea facil-itatorofintegratedandcoordinatedcare,butisnotnecessarilya prerequisite[32,71].Theuseoftechnologyshouldbetailoredto themulti-morbidperson’sabilities.ExamplesofICTapplications atthemicrolevelincludeelectronicmedicalrecords(EMRs)and patientportals.EMRsare pointedout intheliteratureasbeing supportiveinfacilitatinginformation exchangebetween profes-sionals, organisations,patients, and informal caregivers [37,85], linkingclinicalandmanagementinformation[49],improving com-munication[84],allowingfor flexible accesstoup-to-datedata
[49,74],proactivelyfindingpersonswithmulti-morbidity[39,46], trackingprogressandchange[46,49,60],andprovidingreminder prompts[60].Patientportalscanpromoteself-managementand prioritization[37,72].Asideallypatientportalsshouldbelinkedto EMRs,agreementsneedtobemadewiththepatientaboutwhich professionalshavepermissiontoaccesstheEMR[39].
E-healthtoolsortelemedicinecancontributetotheabilityof personswithmulti-morbiditytoliveanindependentlifeintheir ownhomewithimproveddistantcarefacilities[34].Forpersons still livingat homethis caninclude assistive technologiessuch as activity observation or fall detection [114]. Furthermore, e-healthtoolsoftenaimtoimproveandmonitorself-management, forexampleviaweb-basedandtelephoneconsultations,reminder systems[formedicationintake],andremotemonitoringof clini-calindicatorssuchasbloodpressure,bloodsugar,musclestrength, oxygenlevel,andlungfunction[83,110,115,116].
3.2.6.2. Meso.
Consideringthemultipleprovidersandcaresettingsinvolved,a sharedinformationsystem(e.g.,EMRsincludingcareplans)thatis accessiblebymultipleprofessionalscangreatlyfacilitate commu-nication,person-centeredness,tailoredcare,andcarecoordination
[16,21,48,51,62,74,111,115].Suchsharedinformationsystemscan supportcontinuityofcarebetweenorganisationsandthroughout thecareprocess[41,74,81,87,117].ThedifferentICTsystemsused bydifferentorganisationsinvolvedinthecareprocessofaperson withmulti-morbidityunderlinetheneedtodevelopinteroperable systemsorlinkedinformationsystems.
3.2.6.3. Macro.
Nationwide policies that foster technological development and innovation,especiallywithregardtoICTande-healthwilllikely benefitintegratedcareformulti-morbidity[34].Furthermore,the availability of and equitable access to technologies mentioned before(e.g.,remotemonitoringsystems,internetinruralareas) aswellasotherinnovativeandeffectivemedicalproducts(e.g., personalizedmedicine,miniaturizedpacemakers,insulinpumps, pharmaceuticals,imagingtechnologies)areimportanttoimprove thequalityoflifeofpersonswithmulti-morbidity[31].
3.2.7. Information&research 3.2.7.1. Micro.
Individualleveldatashouldbeeffectively usedinthecare pro-cess.Specificallyforcontinuityofcarethiscanincludenotifications ofemergencydepartmentvisitstothecoreteamofprofessionals
adversechangescanpromptcare[118]and computerized algo-rithmsthatrecommendcarepathways[51].
3.2.7.2. Meso.
Wheninformation is sharedandused bymultiple personsand providers,dataownershipandprotectionneedtobeconsidered. Linkedinformationsystemswherebydifferentprofessionalsorcare organisationshavedifferentlevelsofaccesstodatadependingon thecaseathandcouldbeconsidered.Therearealsomorepragmatic approachessuchashavingprofessionalspostedatone-another’s sitestoallowforaccess.
Informationcollectedmayfurtherbeusedforriskstratification bothattheindividualandgrouplevel.Triagesystemsand predic-tivemodelling,forexamplebasedonEMRandquestionnairedata, canstratifypatientsintodifferentlevelsofcomplexityinorderto matchcareandestimatefuturecareneeds[81,86].Such stratifica-tioncanalsoinformfuturecapacityplanning[38,71]andbudget planning[33].
Innovativeresearch[methods]inthefieldof integratedcare andmulti-morbiditycouldassistinincreasingtheevidence-baseof complexinterventionsandbringingresearchfindingsintopractice
[57,103].Inordertoadoptaholisticapproachtoindividualswith multi-morbidityinresearch,usingalifecourseperspective[119]or applyingsequenceclusteringmightbeinterestingfuturedirections
[120].Differentintegratedcareprogrammesformulti-morbidity exist(seeStruckmannetal.,submitted),however,evaluation meth-odsareheterogeneousandfindingsmixed[10,56,102].Attributing causalityisdifficultinevaluationsofsuchcomplexinterventions wheretherearefrequentlynocontrolgroupsorstandardoutcome indicators [32,87,91,97]. However,advanced statistical analyses andinnovativestudydesignsarebeingproposedtoimprovethe evidence-base.Multidisciplinaryresearchiscalledforthat incor-poratestheperspectivesofdifferentgroupsofstakeholders,such as persons with multi-morbidity and their informal caregivers
[12,97,105].Thereis alsoa need todevelop indicatorsthat are particularlyrelevantforthecareofpersonswithmulti-morbidity, forexampleindicatorsrelatedtothelevelofintegrationbetween healthandsocialcare,continuityofcare,andpolypharmacy. 3.2.7.3. Macro.
Alongsidedataownershipatthemesolevel,privacyanddata pro-tection legislation with regard to information sharing between multipleorganisationsisanimportantconsideration[34]. Further-more,policiesthatstimulateresearchinthefieldofintegratedcare andmulti-morbidity(e.g.nationalresearchprogrammes)can ben-efitinnovation,care,andultimatelypersonswithmulti-morbidity. Accesstoinformationmaybeanimportantissueinparticular forpersonswithmulti-morbidity.Disease-specificinformationcan beeasilyfoundontheinternet,butinformationonnavigatingthe caresystem(e.g.,whotoseewhenandforwhat,whoisresponsible, whatis[not]coveredinaninsurancepackage)ismoredifficultto findandisinturnimportantformotivation,adherence,and self-management.Themediamaybeanincreasinglyimportantmeans topromoteaccesstoinformationandpromotinghealthliteracy. 3.2.8. Monitoring
Animportantelementthatrelatestothesixcomponentsandin particulartoinformationandresearch,ismonitoringofthetriple aimofintegratedcare,i.e.,simultaneouslyimprovingpopulation health,improvingpatientexperience,andreducingcost(increase)
[121,122].Monitoringcantakeplaceatthecoreoftheframework, andthemicro,meso,andmacrolevelsandcanfunctionasameans of providing feedback and stimulating constant improvement.
[19,21].Atthecoreandmicrolevels,thiscanpertaintopro-active monitoringofchangesbetweenfacetofaceencounters[88,115]
andthemonitoringofcareplans[73],self-management[82],
clin-icalindicators[79],andpreferences[66].Monitoringthesefactors repeatedly can ensure that care remains tailored and matches needs[45,66,104].Atthemesolevel,continuousmonitoringusing aqualityimprovementsystemcanaidperformance-based man-agementandpay-for-performance,andcanprovideinformation onorganisationalandstructuralintegrationthatmayleadto opti-mizationinprocesses[31,68].Atthemacrolevel,monitoringcan support information onthe workforce-demography match and provideepidemiologicaldataontheprevalenceandincidenceof multi-morbidityinsociety.
4. Discussion
Theframeworkpresentedinthisarticlestructuresrelevant con-ceptsandelementsofintegratedcareformulti-morbiditythatwere identifiedintheliteratureandthroughinternationalexpert meet-ingsoffivestakeholdergroups,i.e.,patients,partnersandinformal caregivers,professionals,payers,andpolicymakers.By connect-ingconceptsandgroupingthemintosixcomponentswiththree levelspercomponent,andaddingandhighlightingissues partic-ularlyrelevantformulti-morbidity,acomprehensiveframework thatwillhopefullyshowtobeapplicableindifferentcontextswas developed.Theconceptsateachlevelandwithineachcomponent shouldcontributetothedevelopmentand(re-)organisationof inte-gratedcaremodels.Integratedcare,astheframeworkshows,isnot anoun,butinsteadisanactiveprocessthatspansacross differ-enthealthcaresectors(e.g.,primary,secondary,tertiary),between health-social-andcommunity sectors,and canalsogobeyond thesetoincludechurches,employers,housing,localcommunities, andeducation.
Theframeworkcanbeusedasastartingpointtosystematically describeintegratedcareprogrammesformulti-morbidity (micro-meso) andtheirrespectivetarget groups(the core)withintheir respectivecontexts(meso-macro).Suchstructureddescriptionscan aidcomparisonacrossprogrammesbymakingvariationsatall lev-elsandcomponentsexplicitandcanprovideinputfordesigning evaluationsofintegratedcareprogrammesformulti-morbidity.
Ascanbeseenbythelengthofthedescriptionsandnumber ofreferencespercomponent,level,andconceptdescribedinthe framework,mostfindingsinthescientificliteraturepertainedto thecore,microlevels,andtheservicedeliverycomponent.Much lessliteraturewasfoundonmacrolevellegislationandpoliciesto supportintegratedcareandonfinancing.Thiscouldbeduetothe broadsearchtermsused,butalsoreflectsthatthesetopicsareless frequentlyaddressedinthescientificliterature.Furthermore,asthe scientificliteraturesearchwasrestrictedtotheEnglishlanguage, national policydescribedin non-English journalsmaybe miss-ing.However,thegreyliteratureandstakeholderadvisoryboard meetingsallowedforcross-nationalinsightsonallconceptsofthe framework.Weconsidertheuseofmultiplemethodsinthe devel-opmentoftheframework amajorassettothisstudy.Afurther strengthofthepresentedframeworkisthatconceptsatthemacro levelaredescribedthatarerelevantinintegratedcarefor multi-morbidity,thesecanbeconsideredwhenaddressingtransferability and[larger-scale]implementation.
made−someconceptsaregenerallyseenasrelevantandimportant inintegratedcare.
Throughouttheiterativeprocessofdevelopingtheframework, severaltopics ledto debate,for instanceon the expected role of the individual with multi-morbidity and the informal care-giverthroughoutthecare process.We decidedtohighlightthe importanceofunderstandingtheentiresituationofthe individ-ualwithmulti-morbidity,includinghis/her social network, and subsequentlytailoringcareasappropriate.
Furthermore,therewassomedebateastowhetherconcepts includedintheframeworkshouldbeevidence-based.Werealized, however,thatthebodyofliteratureontheeffectivenessof inte-gratedcareprogrammesformulti-morbiditywasstilltoolimited. Wethereforedecidedtoincludeconceptsthatweredeemed rele-vantbasedonexperts’opinionsorbecausealogicalmechanismof actionwaspresented.
Fortunately,theinterestandevidenceinthisfieldisgrowing rapidly.Weconductedanupdatedsearchfortheperiodbetween October2015andMarch2017inonedatabase,i.e.,PubMed,which resultedin330newhits,and17potentiallyrelevantarticles.These articlesseemtoreiterateandsupporttheconceptsalready high-lightedin theSELFIE framework.We plantoupdatetheSELFIE framework inthe future.This willbedoneonthe basis ofthe greyandscientificliterature,aswellasontheevaluationsof17 integratedcareprogrammesformulti-morbiditythatarecurrently beingevaluatedintheSELFIEproject.
Paralleltothedevelopmentofourframework,the Multimor-bidityCareModelwasdevelopedbytheEUJointActiononchronic diseases and healthy ageing acrossthe life cycle (JA-CHRODIS)
[123,124].Thismodelidentifies16componentsofintegratedcare formulti-morbidity which are allcovered in theSELFIE frame-work.TheSELFIEframeworkincludesawiderrangeofconceptsand structurestheminadifferentformandencompassesanexplicit layeringof themicro, meso,and macrolevels.Both theSELFIE frameworkandtheJA-CHRODISmodelprovideimportantinsights forthedevelopment,organisation, and evaluationof integrated careformulti-morbidity.
5. Conclusion
Thepresentedframeworkbuildsuponexistingframeworkson integratedandperson-centredcareandsystematicallyaddresses integrationof careatthemicro,meso,andmacro level accord-ingtothesixkey[WHO]components.Theframework’susability willbetestedindescribing variousintegratedcareprogrammes formulti-morbidity in eight Europeancountriesand willguide thedevelopmentofananalyticalevaluationframeworkforthese programmes.
Acknowledgements
WewouldliketoacknowledgetheSELFIEInternational Stake-holder Advisory Board and the SELFIE National Stakeholder AdvisoryBoardsfromtheNetherlands,Austria,Croatia,Germany, Hungary,Norway,Spain,andtheUnitedKingdomfortheir reflec-tionsandcontributionstotheframeworkdevelopment.Wewould liketothankJudithGulpers,GustaDrenthe,andAnneSprangerfor theirhelpwiththescopingreviewandMaaikeVergouwenfor help-ingdesigntheframework.TheSELFIEprojecthasreceivedfunding fromtheEuropeanUnion’sHorizon2020researchandinnovation programmeundergrantagreementNo634288.Thecontentofthis publicationreflectsonlytheSELFIEgroups’viewsandthe Euro-peanCommissionisnotliableforanyusethatmaybemadeofthe informationcontainedherein.
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