Target WP7 - Ricapps

The network

research programme

03

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

Coordinator

Isabel del Cura

Madrid Research Group

RD24/0005/0015

isabel.cura@salud.madrid.org

Participating Groups

Cardiocat. IP:

Rafel Ramos (RD24/0005/0001)

BIPS. IP:

Álvaro Sánchez (RD24/0005/0017)

EpiChron. IP:

Antonio Gimeno (RD24/0005/0013)

Sant Joan de Déu. IP:

Montserrat Gil (RD24/0005/0007)

Canary Islands. IP:

Lilisbeth Perestelo (RD24/0005/0003)

BIODONOSTIA. IP:

Itziar Vergara (RD24/0005/0026)

Navarra. IP:

Berta Ibáñez (RD24/0005/0024)

H. Costa del Sol. IP:

Maximino Redondo (RD24/0005/0016)

F. Avedis Donabedian. IP:

Carola Orrego (RD24/0005/0025)

GRAPP-caIB. IP:

Alfonso Leiva (RD24/0005/0008)

IMIM. IP:

Maria Sala (RD24/0005/0002)

Biosistemak - OSI Bilbao-Basurto. IP:

Amaia Bilbao (RD24/0005/0019)

GRENSSAP. IP:

Anna Berenguera (RD24/0005/0005)

Madrid. IP:

Isabel del Cura (RD24/0005/0015)

Valencia. IP:

Isabel Hurtado (RD24/0005/0009)

Biosistemak - OSI Barrualde-Galdakao. IP:

Susana García (RD24/0005/0020)

ISCIII. IP:

Maria João Forjaz (RD24CIII/0001/0002)

Research lines

Line 1 Patient-oriented interventions with chronic conditions, multimorbidity or frailty to improve health outcomes. This would include any interventions primarily directed at individuals, e.g. education or empowerment and self-management support.

Task 1. To compare the effectiveness and 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 and cost-effectiveness and implementation of multifocal interventions to address frailty in primary care.

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

Line 2 Professional interventions: to achieve role changes and competency enhancement of primary care professionals to improve health outcomes in patients with chronic diseases. Addressing training in competencies and skills, understanding the processes of clinical reasoning, behavior, and perspective of professionals in the care of patients with multimorbidity to develop interventions that modify behaviors and improve empathy, communication skills, and the quality of the processes and care provided to patients.

Task 1. To understand primary health professionals clinical reasoning processes and their perspectives involved in managing patients suffering from multimorbidity. with individual chronic diseases (including cancer), multimorbidity and polypharmacy in primary care.

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

Task 3. To compare the effectiveness and cost-effectiveness and implementation of interventions to improve the skills and competencies of primary care professionals and to analyze usability and human factor affecting the use of CDSS in the management of chronic diseases, multimorbidity and frailty.

Line 3 Organizational interventions: Organizational changes made through professionals or directly to patients will be evaluated. As well as care coordination interventions, i.e., changes in how, when and where health care is organized and delivered, and by whom. All of these aspects have greater potential to improve primary and secondary outcomes in older adults with chronic disease and multimorbidity.

Task 1. To compare the effectiveness of interventions, strategies, and different care pathways in continuity of care processes to improve care and reduce fragmentation and its negative consequences in the care of people with chronic diseases and multimorbidity.