Work package 9 – Toolkit for Implementation

In this final WP, a toolkit will be developed which is a final compilation of all the deliverables produced in the former WPs, in order to ensure a coherent and complete implementation of all the facets of the new chronic care management model (including guidelines for professionals, educational information for patients etc.) in the ‘real world’ of health care. The toolkit has a twofold purpose: 1) providing guidelines for the implementation of the MANAGE-CARE MODEL and 2) providing a blueprint for the development of similar chronic care models in the field of other chronic diseases with possible comorbidities. First of all, the toolkit will provide the necessary guidelines to successfully implement the MANAGE-CARE MODEL. A crucial part in this will be the “10 care-standard recommendations”; defining the ten most important but relatively easily applicable principles to bring integrated chronic care management into practice. These recommendations do not address specific carers but will apply to all carers (formal and informal, in different settings) including the patient him/herself. They can be used as a list of core-values to bring chronic care into practice and/or as a checklist by which the level of integrated care can be quantified. The recommendations will be widely distributed in the form of handy leaflets which are easily readable and very accessible for all users. Secondly, the toolkit will provide guidelines which can help in the development of chronic care models of other primary chronic diseases with potential comorbidities. Now that an innovative chronic care model has been successfully defined in the area of care management for elderly with T2DM, this model and its according guidelines can be used as an example (blueprint) for the development of chronic care management models in the area of other chronic diseases.