Multimorbidity Management Supported by a Digital Platform
Chronic Disease
About this trial
This is an interventional health services research trial for Chronic Disease focused on measuring Primary Health Care, Information Management, Research Design, Telemedicine, Digital Health, Patient-Centered Care, Goal-Oriented Care
Eligibility Criteria
Inclusion Criteria:
- community-dwelling people
- aged 50 or older
- with complex multimorbidity (co-occurrence of three or more chronic conditions affecting three or more different body systems)
- with access to an Internet connection and a communication technology device
Exclusion Criteria:
- inability to: provide informed consent, to read or write, inability to access an email or electronic device, even when helped by an informal caregiver
Sites / Locations
Arms of the Study
Arm 1
Arm 2
Experimental
No Intervention
METHIS Intervention
Control
The METHIS intervention will consist of two components. The first component is a Goal-Oriented Care (GOC) Training Program for health professionals. The training program will include the concept of personalised care, methods of goal elation, implications of GOC in healthcare practice, and how METHIS platform can be used to support the application of GOC. The training will be implemented through a blended-learning, continuous education program that will be credited by Nova University of Lisbon. The second component is a GOC information system. This will be the digital platform METHIS, which will be designed to nudge clinicians to adopt a GOC and to encourage patients and caregivers to take an active role in healthcare. The investigators will adapt an existing platform that was developed for a pilot study during the COVID-19 pandemic, that promotes care coordination, optimises disease prioritisation, and patient self-management.
The control group in this trial will be the best usual care, using the standard Electronic Health Records available to the practice. Our understanding of what "best usual care" is for people with multimorbidity is informed by qualitative research in an earlier stage of this project. Our results suggest that healthcare professionals often provide disease-driven care. When faced with multiple healthcare problems, they prioritise based on 1) patient complaints; 2) which condition is less well controlled; or 3) which condition is more likely to adversely impact on patient Health Related-Quality of life. General practitioners and primary care nurses are often not familiar with the Goal-Oriented Care model. However, they already try to implement some of its principles such as identifying patient goals and supporting shared decision making.