Table 2.
Management of multimorbidity*, examples of DMPs covering COPD and/or diabetes
| Diabetes | |
|---|---|
| Belgium Care pathway diabetes type 2 | Not linked with other DMPs; no specific multimorbidity approach |
| Germany National policy, regional DMPs (diabetes type 2) | Not linked with other DMPs; multimorbidity is not considered |
| Italy IGEA (diabetes type 2) | Not linked with other DMPs; no specific multimorbidity approach |
| Region Tuscany’s Plan (diabetes type 2) | This is a general reorganization of the regional health‐care system, which applies disease management to five conditions: diabetes type 2, COPD, stroke, heart failure and hypertension. Patients who have more than one of these conditions are managed by one team |
| Leonardo (diabetes type 1 and 2) | Not linked with other DMPs. No specific multimorbidity approach, but the GPs and care managers have the competencies to address multimorbidity. |
| The Netherlands National policy, regional DMPs (example: Diabetes Care System West‐Friesland) (diabetes type 2) | Not linked with other DMPs. The Diabetes Care System West‐Friesland is currently involved in an RCT on case management for diabetic patients with multimorbidity. |
| UK (England) National Service Framework for Diabetes (diabetes unspecified) | Linked with DMPs for coronary heart disease and stroke. In addition, universal care is provided under NHS. |
| COPD | |
| Germany National policy, regional DMPs | Linked with DMP for asthma. Patients can participate in several DMPs, but every single DMP is disease‐specific. |
| Italy Region Tuscany’s Plan | See above (diabetes) |
| The Netherlands National policy, regional DMPs (example: De Kroonluchter) | DMP ‘De Kroonluchter’ is currently developing an application to deal with prevalent comorbidities. |
| UK (England) National Strategy for COPD 2005, including asthma | Not linked with other DMPs, but universal cares is provided under NHS. |
DMP, disease management programme.
*Information about the management of functional and participation problems as well as information about the support for self‐management by European DMPs can be obtained from http://www.nivel.nl/pdf/Rapport‐chronic‐disease‐management‐matrix‐2010.pdf (31).
Source: Rijken & Bekkema 31 .