A multidisciplinary reference framework to support innovative design, implementation and assessment of chronic care models

Abstract

There is little evidence to suggest that older people today are experiencing acceptable level of health and quality of life. Most of the health problems of older age are linked to Chronic Diseases. A paradigm shift in the provision of healthcare is required to solve this problem. Despite the continuous emerging of medical innovations, the way they are delivered is still not efficient, effective and consumer friendly enough. New approaches, new ways of collaboration among multidisciplinary research teams and taskforces, are needed.Chapter 1 introduces the problem, the motivation and scope of the research work. Then, a multi-disciplinary and multi-domain analysis further elaborates on the problem, and the main conclusions are drawn.10 1) ensuring universal coverage; 2) provision of care free at point of use; 3) delivery system focused on prevention; 4) priority given to self-maanagement and to 5) primary care; 6) population management emphasized; 7) care integrated to enable primary care teams to access specialist advice and support; 8) exploit the benefits of IT; 9) ensure effective coordinated care; 10) link the 9 characteristics into a whole strategic approach to change (Ham, 2010) 11 1) physician leadership; 2) measuring patient outcomes; 3) best way of incentives; 4) community engagement