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

Mieke Rijken¹, Nienke Bekkema, Pauline Boeckxstaens

¹Head of research programmePhD student, Netherlands Institute for Health Services Research (NIVEL), Utrecht, the NetherlandsPhD student, Department of Family Medicine and Primary Health Care, Ghent University, Ghent, BelgiumProfessor, Department of General Practice, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, the NetherlandsHead of research department, Netherlands Institute for Health Services Research (NIVEL), Utrecht, the NetherlandsProfessor, Department of Family Medicine and Primary Health Care, Ghent University, Ghent, BelgiumProfessor, Department of Family Medicine and Primary Health Care, Ghent University, Ghent, BelgiumDirector, Netherlands Institute for Health Services Research (NIVEL), Utrecht, the Netherlands.

Health Expectations : an International Journal of Public Participation in Health Care and Health Policy

|June 21, 2012

Summary

European disease management programmes (DMPs) often fail to address multimorbidity and patient-defined needs. Improvements require focusing on patient-relevant outcomes and a comprehensive primary care model for better self-management.

Keywords:

chronic illness disease management goal-oriented care multi morbidity patients’ needs self-management

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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.