Micro-level of care |
Self-management support |
Trustful and respectful professional-patient |
Through careful listening and efficient communication, trustful and respectful professional-patient relationships can be established for the delivery of population and/or individual healthcare. |
Active engagement of patient(s) |
Healthcare professionals transfer the accountability for healthcare to patients, encourage patients to engage in the whole healthcare process, and ensure that patients are active partners in healthcare instead of passive recipients. |
Active engagement of informal caregiver(s) |
Recognition and support of the important role played by spouses, adult children, and other informal caregivers is necessary due to the limited consciousness and mobility of some patients. Informal caregivers should be involved in decision-making, care planning, transitions between different healthcare settings, and patient self-monitoring and self-management at home. Meanwhile, informal caregivers’ needs, quality of life, and burden of caregiving should also be considered as they may have health problems themselves. |
Tailored information support |
Healthcare professionals provide patients with tailored information, including disease process, signs and symptoms, healthy behaviors, medication effects, adverse drug reactions, efficient communication skills, self-monitoring methods, and use of health services, through face-to-face and telephone consultation, in-person education either individually or part of a group or community, and written, audio-visual or online materials. All information provided to patients should be tailored to their needs and capacities and kept out of medical terms. |
Accessible and timely contact options |
Healthcare professionals and emergency teams are accessible by telephone and/or e-health tools and can provide timely consultation, education, monitoring, outpatient and inpatient appointment, and emergency services to patients. |
Meso-level of care |
Delivery system redesign |
Comprehensive geriatric assessment |
Regular, comprehensive, and interdisciplinary geriatric assessment during patients’ first visit and subsequent health-related events should be conducted to update patients’ sociodemographic and health-related information. Sociodemographic information includes patients’ age, sex, marital status, primary informal caregiver(s), income, medicare insurance, and other details. Health-related information includes patients’ physical and mental health, living environment, unhealthy lifestyles, functional status, health-related quality of life, healthcare service utilization, healthcare costs, disease and treatment burdens, healthcare needs, priorities, preferences, goals, health literacy, medications’ names, doses, frequency, approaches, and so on. Multiple methods can be used to gather the above information such as electronic health records reviews, standardized questionnaires, patient surveys in healthcare settings or their homes, and direct observations. |
Risk identification and prediction |
Following the completion of a comprehensive geriatric assessment, patients’ risk identification and prediction should be conducted to identify potential complications and determine the appropriate level of healthcare required. |
Individual care plan |
To address patients’ multiple health conditions at the same time, an individual care plan should be created, implemented, and monitored by interdisciplinary teams based on the results of a comprehensive geriatric assessment. After each comprehensive geriatric assessment of patients, their individual care plans should be reviewed and modified to address patients’ evolving health problems, needs, priorities, preferences, and goals. Any changes of the individual care plan should be shared within interdisciplinary teams, patients, and informal caregivers. Printed or online care plans shared with patients may further improve their adherence. |
Interdisciplinary team |
The interdisciplinary team includes different practitioners (general practitioner, nurse, pharmacist, social worker, physiotherapist, occupational therapist, dietitian, rehabilitation therapist, and so on), different specialties (geriatrics, internal medicine, cardiology, oncology, psychiatry, and so on), and different levels of healthcare (primary healthcare, outpatient specialized care, hospitals, emergency department, and so on). The roles, responsibilities, and accountabilities of team members are highly clarified. |
Case manager |
The case manager is a trained healthcare professional serving as a point of contact for the patient and each healthcare professional involved in the healthcare process to ease communication, enhance effectiveness, reduce care fragmentation, and facilitate continuity of care and transitions across care settings. |
Primary decision-maker |
The role of a primary decision-maker is important when making a patient’s overall care decisions. |
Decision support |
Evidence-based practice |
Disease-specific guidelines should be used with considerations of the heterogeneous nature and therapeutic competition of multimorbidity, and be applied together with healthcare professionals’ clinical expertise and patients’ preferences. Guidelines for multimorbidity are urgently needed. Clinical pathways and computerized decision support systems are tools to support evidence-based practice. |
Professional training |
The focus of professional training should be primarily on prominent members of interdisciplinary teams, particularly on experts or specialists who administer regular and vital care or treatment to patients. The following knowledge and skills should be provided: screening and identification of multimorbid patients, comprehensive geriatric assessment, drug-disease and drug-drug interactions, adverse drug reactions and solutions, shared decision-making and goal-setting methods, design and implementation of individual care plans, working effectively as a team, efficient communication skills, critical appraisal and implementation of evidence-based knowledge, and health education. |
Shared decision-making |
The interdisciplinary teams take into account various factors such as patients’ healthcare goals, preferences, and prognosis, as well as the complexity and feasibility of treatment when making clinical decisions. Additionally, they strive to ensure the active engagement of patients and their informal caregivers during the decision-making process. Patients’ goals refer to personal health and life outcomes that patients hope to achieve through their healthcare. Patients’ preferences refer to what patients are able and willing to do to achieve their goals as well as the time, inconvenience, discomfort, and money in completing these tasks. Patients’ prognoses refer to their remaining life expectancy, functional status, quality of life, and so on. |
Consultation system to experts outside of the interdisciplinary teams |
Incorporating the participation of external experts, such as medical specialists and advanced practice nurses, offers the advantage of ensuring the continuity of individualized care plans while allowing a high level of professional input. |
Clinic information systems |
Uniform coding of health conditions |
Patients’ health problems, patient-reported outcomes, healthcare utilization, and other concepts such as patient preferences, should be standardized through uniform coding and consistent definitions to promote information-sharing between different healthcare professionals and settings. |
Electronic health records system |
Healthcare professionals keep track of patients’ medical histories, diagnoses, symptoms, medications, needs, priorities, preferences, goals, and other important information and record this information in the electronic health records system to promote information-sharing. Patients and their informal caregivers can obtain this information through patient portals. |
Information-sharing |
With the permission of patients, electronic health records should be shared among patients, informal caregivers, and healthcare professionals across different disciplines, organizations, and levels of healthcare. Data ownership and protection also need to be considered in this process. |
E-health tools |
The use of e-health tools, specifically patient-operated technologies, offers numerous benefits regarding healthcare. These tools empower patients to send information to healthcare professionals and schedule appointments, while also enabling healthcare professionals to view, monitor, and respond to this information. As a result, e-health tools have the potential to enhance in-person visits, particularly for patients who reside in remote areas, lack social support, or have limited mobility. They also contribute to increased access to interdisciplinary resources, improved self-management for patients, and enhanced monitoring of clinical indicators by healthcare professionals. Assistive technologies such as medication-taking reminders and ePrescription services are also helpful. |
Healthcare organization |
Human resource management |
To achieve sustainable development, it is essential to have suitable human resources and visitation time for healthcare professionals. This allows them to establish close relationships with patients and their informal caregivers and implement personalized care plans at the organizational level. |
Supportive leadership and environment |
Supportive leadership should promote the adoption of new healthcare models, management methodologies, and information and communication technologies. It should be prepared for change, ensure transparency within the organization, and establish clear accountability. Additionally, supportive leadership should create opportunities, allocate sufficient time, and provide healthcare professionals with value-based financial incentives. A supportive environment, on the other hand, pertains to the culture within the healthcare setting. This culture should embrace shared philosophies, values, and visions, such as patient-centeredness, collaboration, coordination, and caution. Furthermore, the establishment of effective communication channels promotes collaboration, coordination, and the development of mutual trust and respect among professionals from diverse disciplines. |
Quality tracing and continuous improvement |
Healthcare organizations should formulate suitable quality metrics with the aim of evaluating the efficacy of various treatments, interventions, and healthcare services provided to patients. Additionally, these metrics could serve as a basis for carrying out continuous enhancements in clinical practices, supported by robust evidence. |
Organization collaboration |
The collaboration between healthcare organizations across different levels is essential in reducing care fragmentation and achieving continuity of care. To achieve these goals, it is imperative to establish both fully integrated formal alliances and informal cooperation agreements. |
Macro-level of care |
Community resources and policies |
Health education and promotion programs |
Communities provide health education and promotion programs with the engagement of trained volunteers regularly, such as nutrition and exercise programs, peer-support programs, adult daycare centers, and psychosocial consultations. |
Available and accessible healthcare resources |
Governments should construct more infrastructure in public health and long-term care areas to ensure the availability and accessibility of health and social care resources (eg, accessible waiting time, reasonable travel times, wheelchair accessible points, and so one). |
Innovative reimbursement and payment mechanisms |
National or regional government subsidies and private investments are necessary for the reimbursement of costs in health and social care. Moreover, the current payment mechanisms used by both public and private medical insurers, which rely on fee-for-service payments, do not adequately support the additional services offered by emerging healthcare models. Therefore, it is crucial to explore and implement various blended payment mechanisms, such as fee-for-value payment systems that consider patients’ outcomes to ensure the sustainability of the healthcare system. |