Chronic Disease Management Programmes: an adequate response to patients' needs?

Area of Science:

• Healthcare Management
• Chronic Disease Care
• Patient-Centered Medicine

Background:

• European countries are developing disease management programmes (DMPs) inspired by American models to enhance chronic disease care.
• Emerging concerns question the suitability of current DMPs in addressing patient-defined needs.

Purpose of the Study:

• To evaluate the responsiveness of European DMPs to patient needs, focusing on multimorbidity, functional limitations, participation issues, and self-management.
• To identify gaps in current DMPs regarding patient-centered care.

Main Methods:

• A survey of country-experts provided data on existing DMPs.
• International scientific literature was reviewed to supplement survey findings.

Main Results:

• Most European DMPs inadequately address multimorbidity, with limited integration of rehabilitation, psychosocial support, or social environment involvement.
• Tailored interventions for specific patient groups are rare, and few DMPs empower self-management through individualized information and shared decision-making.
• Strategies like linking DMPs, developing comorbidity modules, and integrating case management are being explored.

Conclusions:

• Monitoring patient-relevant outcomes, potentially using the International Classification of Functioning, Disability and Health (ICF) model, is recommended to enhance DMP responsiveness.
• A comprehensive, primary care-embedded model is proposed for managing multimorbidity, emphasizing goal-oriented approaches to prioritize patient goals.