Implementing patient-centred integrated care for multiple chronic conditions: Evidence-informed framework

Fifteen years ago, the term multimorbidity rarely appeared in chronic disease health care policies. Today, research has revealed very high rates of multimorbidity, leading to it being labeled the number one challenge in developed countries. Paradoxically, chronic disease prevention and management (CDPM) programs of integrated care have popped up in all health care systems but they mainly follow a single-disease approach in their interventions. In this article, we define CDPM programs broadly as any interventions intended to improve care for patients with chronic diseases and risk factors; these are added to usual care and are typically delivered by a team. The implementation of new models of patient-centred care for persons with multimorbidity in primary health care faces additional challenges mostly related to a lack of readiness or competing demands. Change management theory and models14 might help circumvent some challenges but these lack specificity for the implementation of integrated care for persons with multimorbidity at the clinical level.