Impact Assessment of an Innovative Integrated Care Model for Older Complex Patients with Multimorbidity: The CareWell Project

Objectives: To evaluate the impact in terms of use of health services, clinical outcomes, functional status, and patient´s satisfaction of an integrated care program, the CareWell program, for complex patients with multimorbidity, supported by information and communication technology platforms in six European regions.

Data Sources: Primary data were used and the follow-up period ranged between 8 and 12 months.

Study design: A quasi-experimental study, targeting chronic patients aged 65 or older, with 2 or more conditions – one of them necessarily being diabetes, congestive heart failure or congestive obstructive pulmonary disease. The intervention group received the integrated care program and the control group received usual care. Generalized mixed regression models were used.

Data collection: Data were obtained from individual interviews and electronic clinical records.

Principal Findings: Overall, 856 patients were recruited (475 intervention and 381 control). In the intervention group, the number of visits to emergency rooms was significantly lower, and the number of visits to the general practitioners and primary care nurses was higher than in the control group.

Conclusion: The CareWell program resulted in improvements in the use of health services, strengthening the role of PC as the cornerstone of care provision for complex patients with multimorbidity.