Target WP7 - Ricapps

The network

research programme

03

WP 7. To compare the efficacy, cost-effectiveness and implementation of interventions and strategies to improve health outcomes for patients with chronic diseases in primary care and continuity of care.

Coordinator

Isabel del Cura

Madrid Research Group

RD21/0016/0027

isabel.cura@salud.madrid.org

Participating Groups

Cardiocat. IP:

Rafel Ramos (RD21/0001/0001)

BIPS. IP:

Alvaro Sanchez (RD21/0001/0003)

EpiChron. IP:

Alexandra Prados (RD21/0001/0019)

Aragon-IACS. IP:

Enrique Bernal-Delgado (RD21/0001/0023)

Canary Islands. IP:

Lilisbeth Perestelo (RD21/0001/0013)

BIODONOSTIA. IP:

Itziar Vergara (RD21/0001/0021)

Navarra. IP:

Berta Ibáñez (RD21/0001/0016)

H. Costa del Sol. IP:

Maximino Redondo (RD21/0001/0015)

F. Avedis Donabedian. IP:

Carola Orrego (RD21/0001/0028)

Galicia. IP:

Francisco Gude (RD21/0001/0022)

IMIM. IP:

María Sala (RD21/0001/0020)

Kronikgune 2. IP:

Amaia Bilbao (RD21/0001/0011)

Madrid - AP. IP:

César Minué (RD21/0001/0026)

Madrid. IP:

Isabel del Cura (RD21/0001/0027)

Valencia. IP:

Isabel Hurtado (RD21/0001/0006)

Research lines

Line 1 Patient-oriented interventions for patients with chronic conditions, multimorbidity or frailty to improve health outcomes. More than half of older adults (age ≥ 65 years) have 2 or more chronic conditions with a high burden of multimorbidity and polypharmacy; however, most existing chronic disease management interventions focus on a single condition. This would include any intervention aimed primarily at individuals, for example, education or empowerment and support for self-management.

Task 1. To compare the effectiveness, cost-effectiveness and implementation of complex interventions to improve health outcomes in patients with individual chronic diseases (including cancer), multimorbidity and polypharmacy in primary care.

Task 2. To compare the effectiveness, cost-effectiveness and implementation of multifocal interventions to address frailty in primary care.

Task 3. To compare the effectiveness, cost-effectiveness and implementation of information and communication technology (ICT) interventions to improve health outcomes in patients with chronic diseases in primary care.

Line 2 Professional interventions: producing role changes and improving the competence of primary care professionals to improve health outcomes in patients with chronic diseases. Training aimed at changing professionals’ behaviour, improving communication skills and empathy, raising professionals’ awareness of multimorbidity, and providing targeted training to equip doctors with the skills required to manage these patients and their treatments, thereby improving their healthcare.

Task 1. To compare the effectiveness, cost-effectiveness and implementation of interventions to improve the skills and competencies of primary care professionals in the management of chronic diseases, multimorbidity and frailty.

Task 2. To compare the effectiveness and cost-effectiveness, and the implementation, of interventions aimed at redefining or adapting professional roles in the care of people with chronic diseases, multimorbidity and frailty in primary care.

Line 3 Organisational interventions: Organisational changes implemented through professionals or directly for patients will be evaluated. As will care coordination interventions, that is, changes in how, when and where healthcare is organised and delivered, and by whom. All these aspects have greater potential to improve primary and secondary outcomes in older adults with chronic diseases and multimorbidity.

Task 1. To compare the effectiveness of various pathways in care continuity processes in caring for people with chronic diseases and multimorbidity.

Task 2. To compare the effectiveness and cost-effectiveness of interventions and strategies to reduce fragmentation and its negative consequences in primary care.