Delegating chronic care management to primary care: the new chronic care model in Lombardy

Good practice:

Empower patients to ensure they agree with support plans

LOMBARDY  / CReG (Chronic Related Groups):  486/22227 44/250

The Lombardy region has a population of 10 million inhabitants, with over 4.6 million NCD patients. Most of them are over 65 years. They are affected by one or more pathologies (76% affected by at least one comorbidity, and 49% by at least two). The situation is even worse for those who are over 74 (86% and 68%, respectively). 

Based on recent data shared by Lombardy Region, the percentage of chronic patients increases with age, with a particular accent between 40 and 80 years old patients. Patient care for older subjects use a high percentage of the overall costs.

Customer's need

Chronic diseases are characterised by a long duration and generally slow progression. The challenge is to deal with the complexity of these diseases. Given the long life of patients with chronic conditions, it is important to ensure care coordination for acute events, and prevent relapses. They include:

  • Non-Communicable Diseases – cardiovascular disease, cancer, chronic respiratory diseases, diabetes, mental disorders, skeletomuscular diseases, etc.
  • Communicable diseases such as HIV/ AIDS 
  • Genetic disorders like cystic fibrosis – included because of the survival rates and the duration.

The solution

The regional government launched an innovative programme called CReG (Chronic Related Groups). This promotes continuity of care in chronic patients for COPD, hypertension, cardiovascular diseases, type 2 diabetes and comorbidities. The CReG mimics a DRG in a territory, by defining a bundle payment system for multimorbid patients. The programme promotes continuity of care, focused on the elderly, for NCD patients and comorbidities. By providing an appropriate care plan, we can reduce implicit costs related to avoidable hospitalisations and acute events.

Keys to success

  • Reduce impact of acute events and emergency visits for chronic patients.
  • Improve chronic patient’s continuity of care.
  • Design new care pathways for multimorbid patients.

Good practice: Empower patients to ensure they agree with support plans.

Good practice description

Managers and frontline staff identified a number of tools to encourage patient adherence. These approaches all involve techniques to empower patients by:

  • Encouraging motivation.
  • Knowledge and skills in self-management.
  • Formulating action plans.
  • Sharing experiences.
  • Problem solving.
  • Communication techniques.
  • Shared decision making.
  • Managing emotions.

Successful strategies involved tailoring information and the participation of all clinicians. Specifically, primary care, hospital, healthcare providers, and encouraging patients to take ownership. Consistent follow-up by professionals is also needed, and the implementation of ‘anti drop-out’ policies. Also import is to ensure treatment plans are reinforced before discharge, at discharge and during follow-ups.

“Strong relationships between patient and healthcare professional is fostered by a good understanding of the patient. This means his pathologies, his mentality, culture, education and perception of the disease.”

Good practice example

Lombardy’s CREG Programme shows excellent results in patient adherence. The key is the distribution of a personalised careplan in paper to the patients. This gives them opportunities to agree or disagree with treatment, and be involved with goal setting. This is designed to improve adherence at all levels of care.

The program

The CReG programme is an innovative solution. Providing a builtin economic model, which promotes care coordination. Five Local Health Authorities (LHA) were involved during the pilot phase. A first scale up to other five LHAs is ongoing and, depending on the additional results, a scale up to the entire region is planned.

The model is based on three pillars:

  • Technological infrastructure to identify and stratify the NCD patients.
  • Care plans (ICP) and medical guidelines.
  • New reimbursement system.

The details of the programme are in the hands of the general practitioner cooperatives. They must guarantee:

  • The definition of a personalised ICP for each NCD patient.
  • Adherence of the patient. 
  • Service centre available for 12 h/365 days, operated by trained personnel.
  • Health data management and indicators evaluation.
  • Patient education.
  • Evaluation of the satisfaction of the enrolled patients

Contact information

Javascript needed

Marco Nalin


  • M. Nalin, I. Baroni, M. Romano, G. Levato, Chronic related groups (CReG) programme in Lombardy, European Geriatric Medicine, Volume 6, Issue 4, July 2015, Pages 325-330, ISSN 1878-7649.
  • Sanità e salute.
  • Il progetto CReG: I primi risultati nella regione Lombardia.

Program partners