Project description
A patient-centred approach for multimorbid patients
An ageing population has resulted in growing numbers of complex multimorbid chronic patients who require medical support. Therefore, modern medicine requires a novel, patient-centred attitude for more effective treatment options, as well as lower costs and better decision-making. The EU-funded GERONTE project will combine expertise in public health and public sector digital transformation to harness digital technology to improve the healthcare outcomes of elderly patients with comorbidities. Using the model of cancer multidisciplinary management, it will co-design with patients, caregivers and professionals a patient-tailored approach that will ease care pathways, management and treatment decisions while reducing healthcare costs.
Objective
Population is aging and the number of complex multimorbid patients to manage will increase sharply. Disease-centred approach is not appropriate to manage these patients. Change to a patient-centred approach will simplify care pathways, secure management and treatment decision making and decrease healthcare costs. It will be a real breakthrough for daily practice with multiple impacts that must be quantified. GERONTE multimorbid patient-centred system proposes:
1) Coordination of management by a patient-tailored, interdisciplinary health professional consortium (HPC), including hospital- and home-based professionals, with a case manager;
2) Timely registration of symptoms and patient-reported outcomes at home through a web-based app for anticipation of avoidable adverse events;
3) Proposal of self-management guidelines according to intrinsic capacity evaluation by geriatrician for patient-driven improvement of independent living;
4) Structured collection of data from electronic health record into a dashboard made available to HPC members as well as patient and caregiver, thanks to its capacity to securely interoperate with all electronic health records including software managing medical data.
The whole approach will be co-designed with patients, informal care givers and health professionals.
Cancer is an excellent model to develop this approach in multimorbid patients because it is frequent and commonly associated with other morbidities in older patients but also because of its major impact on patients’ general status and coexistent diseases. Cancer already benefits from a multidisciplinary management model that GERONTE will enhance, strengthening exchange of holistic data, role of primary care and case management.
GERONTE will also provide new country-specific guidelines and best practices for implementation across Europe and for improved management of older multimorbid patients including improved quality of life and independent living at decreased costs.
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RIA - Research and Innovation actionCoordinator
33000 Bordeaux
France