Project Overview

Specific objectives of the project

  1. Overview and assessment of: 
    • Different European disease management models: systematic overview and structured assessment of the current state of the art of disease and chronic care management models, including both home and institutionalized disease management strategies in practice in the EU Member States. Assessment of the role of formal as well as informal carers.
    • Scientific evidence on care delivery to elderly with T2DM and comorbidities, focusing on the complex interaction between both, on diagnostic and treatment level: Performance of a systematic literature search, summarizing the scientific evidence on care delivery to elderly with T2DM and comorbidities.
  2. Assessment of specific needs and priorities of elderly with T2DM and comorbidities: Assessment of how needs and priorities of elderly with T2DM and associated comorbidities are perceived and addressed in current management models and guidelines (based on the overview described in 1.
  3. Development of a practice compendium focusing on chronic care management in elderly, including 10 standard care recommendations: Development of a European Practice Compendium on the treatment of elderly with T2DM and comorbidities, based on current models, scientific evidence and patient-involvement. Ten practice chronic care standard management recommendations will also be developed.
  4. Development of an innovative practice model for chronic care management of T2DM, addressing the specific needs of an ageing population: following a solid assessment of the state-of-the-art, of scientific evidence and of the needs and priorities of the end-users (i.e. older people with T2DM), MANAGE-CARE will develop an innovative chronic care management model based on Wagner’s chronic care model, ensuring an integrated, team- and patient-centred approach. All key-stakeholders, including end-users will be involved.
  5. Development of a training program for health professionals, based on the new chronic care model, to optimize practice implementation: to ensure an adequate implementation of the chronic care model in practice, a specific curriculum for healthcare professionals will be developed. Since most healthcare professionals are currently used to work in separate entities (fragmentation), the training program will be focusing on team-based care (integration) and adequate prioritization of the multi-faceted needs of the ageing patient.
  6. Development of patient empowerment recommendations, enabling older people to play an active role in managing their chronic disease: since the new chronic care model is patient-centred, empowerment of patients (and their environment) in taking an active role in the management of their condition(s) will take a central place. Individual assessments regarding the specificity of this involvement and individualized prioritization of management goals will be enclosed to ensure a patient-centred approach. The potential use of telemedicine will be addressed as well.
  7. Development of a freely accessible toolkit offering clear guidance on the implementation of the developed model and ensuring transferability of the model to the treatment of other primary diseases with potential comorbidities: based on the outcome of all aforementioned objectives, a toolkit will be developed including a roadmap with specific guidelines for the implementation of the innovative chronic care model. The developed model, focusing on elderly with T2DM as the primary underlying chronic condition, will be made transposable to patients suffering from other primary diseases with potential comorbidities.