CHRODIS: Improving the Multimorbidity Care Model


Experts from the Joint Action CHRODIS (Chronic Diseases and Promoting Healthy Ageing across theLife Cycle) identified two important elements to improve the multimorbidity care model.  

Management of multimorbid patients (patients living with multiple chronic conditions) is broadly recognised as a major issue for health systems. Currently 65% of people over 65 live with multimorbidity and the number rises to 85% for patients aged 85.

Addressing the needs of patients with multimorbidities  is a complex task that brings together a large number of healthcare providers, leads to high consumption of medical treatments, results into high fragmentation of the services delivered to the patients, high costs for healthcare systems and still high risk of failure in meeting patients’ needs.

Because of this threatening scenario, one of the core activities of the Joint Action CHRODIS consists in the development of common guidance and methodologies for care pathways for multimorbid patients.

In the framework of this activity several components have been identified, where two important ones are the definition of a multidisciplinary care team model, and of the Case Manager.

Multimorbidity Care Team Model

CHRODIS partners have reviewed existing integrated care programmes for patients with multimorbidity, developed in the EU Member States and other European countries, and have identified their key characteristics.  Following this, EPF together with a group of medical experts, patients’ representatives, epidemiologists and researchers have identified the key components to build the first comprehensive care model that can improve care for patients with multimorbidity, and ultimately, their quality of life.

The model aims at setting better coordination of care for patients with multimorbidity, ensure better cooperation within the healthcare team, provide patients and family adequate self-management support, and using technologies and social and community resources.

Case Manager

A second important component of the CHRODIS work on multimorbidity consists into the design of the Case Manager profile to integrate into the multimorbidity care team. The role of the Case Manager should be to coordinate the patient’s care plan, manage care, arrange social support, facilitate the integrated care from the multidisciplinary team and also act as an essential contact point for the patient.

In the absence of tailored training programmes for Case Managers, a group including CHRODIS partners and external experts has recently met to discuss the design of a potential training. The aim of the meeting was to define a minimum set of skills, knowledge, and competencies for a person working as a Case Manager for multimorbidity patients in Europe.

The full description of the multimorbidity care model is already available in a report from the work of CHRODIS work package 6. EPF has also published a factsheet to raise awareness about multimorbidity and the CHRODIS multimorbidity care model, and to promote its implementation. The output on case management is going to be published in the coming weeks.   


Valentina Strammiello