Integrated care pathway and organisational model for patients with multimorbidity

Good practice:

Patients are stratified to allow for more personalised and efficient care

BASQUE COUNTRY  / Population Intervention Plan for Multimorbidity (PIP MM):  46/1410 7/55

Compared to patients with only one chronic disease, frail and elderly patients with multimorbidity are responsible for around 49% of the total health costs. They have complex health and social care needs, are at risk from multiple admissions to hospitals or residential care homes, and require a range of high level interventions due to their frailty and multiple chronic conditions.

These patients typically demand an integrated care approach. All care practitioners working in the different levels of care are tightly coordinated, and special emphasis is put on each patient’s empowerment.

Customer's need

Improving the delivery of care for complex patients is a priority around the world and requires overcoming several challenges. As a consequence, there is a primary need to:

  • Move the primary attention away from the disease to patient-centred care.
  • Ensure the continuum of care within Health system and social care system.
  • Provide the delivery of care in the most cost-effective setting, while trying to keep the patient at home.
  • Identify patients at risk to anticipate care. Avoid worsening symptoms and acute decompensation. Introduce monitoring and patient follow up at home.
  • Empower patients and carers in managing their own health condition.
  • Personalise care according the patient’s condition, health status, social, and healthcare needs.

The solution

The aim of the program is to improve the health and social outcomes. The solution is to use a population approach, and define common and shared pathways between different levels of care and common objectives. The resulting population intervention program for multimorbid patients is developed by a collaborative, multidisciplinary team of clinicians and managers. 

Their work has various outcomes:

  • A new organisational model, which includes new roles and new functions.
  • A new common pathway.
  • Proactive patient identification using risk stratification tools.
  • Improved ICT infrastructure, which supports sharing information and patient monitoring.
  • A common set of shared objectives and indicators linked to health outcomes and process improvement.

Keys to success

  • Programme prioritised by Department of Health and linked to the funding of the Health care provider. 
  • Engagement and involvement of managers and clinicians in the definition of the organisational model and pathway.
  • High and common advanced ICT infrastructure for both levels of care, based on Electronic Health Care Record, e-prescription, and Personal Health Care Record.

Good practice: Patients are stratified to allow for more personalised and efficient care.

Good practice description

Patients are stratified according to resource consumption in the previous 12 months. This allows for better care, personalised treatment, and targeted follow-up. High complex patients spend 49 times more resources than patients with only one chronic condition. The adequate identification of this population is essential for the quality of care of frail patients. Giving the capacity to treat them in a more effective manner, and to avoid unnecessary hospitalisations. It also helps to provide a more sustainable system.

This proactive approach improves relationships among health and care professionals. It also anticipates serious events, and ensures the provision of care at an early stage. 

"Risk stratification tools are becoming a key factor in the redefinition of the work among team members."

Good practice example

In the Basque health care system, 33% of patients with chronic conditions consume nearly 70% of the financial resources available. Those with several chronic conditions number 43,000 and are considered complex patients. The Basque Population Intervention Plan for multmorbidity is a service designed for patients with high risk of health events. Proactive identification of patients at future high risk has been achieved through risk stratification tool. Resource allocation for patient needs has been adequately assigned. Expenditures for this patient group has been managed appropriately in a coordinated plan. The overall goal has been to make the health care system more proactive than reactive, and more collaborative than fragmented.

The program

The programme involves several healthcare professionals from different levels of care and settings. Described below are the varieties of activities performed by the agents, which depend the needs of each patient. 

Primary care professionals (GP and primary care nurse) are principally responsible for each patient’s case management, therapeutic / care plan definition, drug prescription, patient training, home visits and follow-up. The communication between healthcare professionals and patient is mainly via traditional channels (face-to-face, phone). Health care professionals can also exchange patient-related documentation over the phone, via a Personal Health Care Record, or by meeting face-to-face on a periodic basis.

Healthcare professionals share patient information through Electronic Health Care Record. Online consultations between healthcare professionals is also available in order to avoid referrals.

The Telecare Centre is in charge of coordinating health and social care professionals. Operators can activate services entrusted to the eHealth Centre. Nurses at the centre are responsible of giving support out of hours following validated protocols. They also give health advice to patients.

Once the patient shows worsening symptoms, additional healthcare actors take part in the caring process. The GP may refer the patient to a specialist if necessary. The deputy health service can be activated on a patient’s request. Clinical interventions can be performed at home by GPs, primary care nurses, and out-of-hour healthcare professionals. 

The reference internist and hospital liaison nurse are the main roles highlighted in hospital care. The reference internist is responsible for carrying out tests and diagnostics, defining the therapeutic plan, following up the pharmacological plan, coordinating specialists, informing GP on patient’s health status, referring the patient to the long-term hospital (if required), and activating hospital social care team when the patient is hospitalised. The hospital liaison nurse, supervises the patient’s hospital discharge. Usually by sharing information with the primary care nurse, and providing patients with information on therapeutic plans and health education.

On hospital discharge, the GP and the primary care nurse perform an intensive follow-up. This includes home-visits. The primary care nurse carries out the patient’s integrated frailty assessment. Depending on the outcomes, the community social services can be activated.

Contact information

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Cristina Domingo Rico


  • Department of Health and Consumer Affairs of the Basque Government and Osakidetza. A strategy to tackle the challenge of chronicity in the Basque Country. 2010.
  • Mora J, de Manuel E, Arratibel P, Paz K, Ureta A. Planning of the local innovation process for the development of Population Intervention Plans in an integrated health system. 2013. 13th international Conference on Integrated Care.
  • Internal source: Osakidetza 2011.

Program partners