Abstract Body

Background:

To reduce the burden of chronic diseases on society and individuals, European countries implemented disease management programmes (DMPs) that focus on a single chronic disease. However, (i) the scientific evidence that these DMPs reduce the burden of a chronic disease in terms of health-related quality of life is not convincing, (ii) patients with multimorbidity may receive overlapping or conflicting treatment advice, and (iii) the single disease approach conflicts with the core competencies of primary care, i.e. medical generalistic, person-centred, and continuous care. The aim of this study was to develop a holistic, person-centred and integrated approach for the management of patients with chronic diseases and multimorbidity in primary care.

Methods:

A mixed-methods study was conducted in the Netherlands from January 2019 to December 2020. First, we performed a scoping review to construct a theoretical model. Second, 57 healthcare professionals commented on the model in online qualitative questionnaires. Third, 9 patients with chronic conditions were interviewed on the model by phone. Finally, the model was presented to 3 local primary care cooperatives and finalized after their comments.

Results:

A stepwise software-supported approach was developed, including (i) assessing patient’s integral health status using (web-based) questionnaires and physical measurements; (ii) discussing the results with a case-manager, after which (iii) treatment goals are formulated, suitable interventions in the primary care network are selected and an evaluation is planned.

Conclusion:

We developed a holistic, person-centred, integrated approach for the management of patients with chronic diseases and multimorbidity in primary care. This approach will be tested in a pilot study in 2021 to establish its feasibility and potential effects.