Work package 6 – MANAGE CARE Model
WP6 contains the core of the MANAGE-CARE project with its development of the CHRONIC-CARE MANAGEMENT model. Unlike most of the current treatment models and treatment guidelines, this model will be a care-focused, instead of a disease-focused model. The model will cover both health- and wellbeing-related aspects in the treatment and care of the ageing patient and will be based on Wagner’s chronic care model. The main aim of this model is to ensure an integrated, team- and patient-centred approach to the complex treatment and care of elderly with T2DM and associated comorbidities as an example for the development of chronic care models for other chronic conditions. The most crucial task in this model development process will therefore be the identification of key components of the new care model, involving all key-stakeholders, including end-users (i.e. elderly patients with T2DM) and ensuring the integration of the information and deliverables produced in WP4 and WP5. Besides the above mentioned key components, the following elements will certainly be addressed and included in the model: 1) Prioritizing treatment goals relative to that of other comorbidities and the functional status of patients. 2) The emerging, interdisciplinary roles of health professionals, (informal) carers and other stakeholders involved in T2DM care management and the interaction between stakeholder groups in this care process. 3) Empowerment of patients in taking an active role in the management of their condition. 4) Using the potential of telemedicine in chronic care management to ensure longitudinal monitoring and assistance. A technical handbook representing this innovative Chronic Care Model will be developed.