Addressing multimorbidity through integrated care solutions

Demographic shifts, multimorbidity, and healthcare challenges

The ongoing demographic transformation across Europe has led to a rapidly aging population, accompanied by a significant rise in multimorbidity – the coexistence of two or more chronic conditions in an individual [1]. By 2050, over 30% of Europeans are projected to be aged 65 or older, and among these, up to 65% will likely face multimorbidity. This demographic shift has profound implications for the sustainability of healthcare systems, which are increasingly strained under the rising demand for resources, specialized care, and municipal care services [2]. Multimorbid persons (PMM) require a complex, interdependent network of care, which is rarely addressed adequately by current care models [3].

Traditional healthcare systems, characterized by diagnosis-specific, episodic, and reactive care delivery, are ill-equipped to address the complex and interdependent needs of the PMM population [4]. These systems typically operate within silos, limiting effective collaboration across care levels and sectors. Furthermore, a lack of information continuity during patient transitions contributes to duplicated efforts, inefficiencies, and compromised care quality. These deficiencies disproportionately affect PMM, who constitute the top 10% of healthcare consumers but account for nearly two-thirds of specialized care expenditures [5]. The rise in PMM patients calls for a shift from diagnosis-specific to person-centered, integrated, and proactive care. While this approach shows promise in improving patient satisfaction, care quality, and access, its efficacy for multimorbidity remains to be fully demonstrated [6]. Integrated care must address both health and social needs while reducing resource use and costs. To achieve this, care providers must adopt a holistic view, incorporating social and environmental factors to better anticipate and manage the complex interplay of coexisting conditions.

Despite the critical need, the market lacks comprehensive technological solutions tailored to the unique requirements of PMM. Available systems are predominantly oriented toward single-disease management and lack the interoperability, holistic data integration, and patient-centered design necessary for multimorbid care [7]. This gap underscores an urgent need for innovative solutions capable of integrating care across multiple levels and addressing the full spectrum of a patient’s needs, including clinical, social, and behavioral dimensions.

Recognizing these systemic challenges, the CareMatrix Challenge was conceptualized under the European Union’s Horizon 2020 framework. CareMatrix seeks to stimulate innovation in integrated care models to address the needs of PMM through a pre-commercial procurement process. The initiative aimed to develop scalable, interoperable, and patient-centric solutions to bridge the gaps in care continuity, support proactive care, and empower both patients and healthcare professionals to improve care outcomes while ensuring the sustainability of healthcare systems.

The INCA solution: Design and integration for holistic care

The INCA (Integrated Care) solution was developed to directly address the gaps identified in the CareMatrix Challenge. It leverages a modular design approach built around five key building blocks: early assessment, interdisciplinary collaboration, individualized care, continuity of care, and patient empowerment. Each block reflects a core principle in the management of multimorbidity, ensuring a comprehensive and flexible solution adaptable to varying healthcare environments. The INCA solution is developed by a multidisciplinary consortium combining clinical expertise from Fight Infections Foundation and Germans Trias i Pujol Research Institute, academic insight from the Open University of Catalonia and Norwegian Centre for E-Health Research, and technological innovation from Doole Health.

The INCA platform operates on a dual interface: a web-based application for healthcare professionals and a mobile application for patients and caregivers. The professional interface includes shared care plans (SCP), a clinical decision-support system, and real-time dashboards for monitoring patient progress. For patients, the mobile app integrates self-management tools, reminders, gamified adherence strategies, and a multichannel communication platform that facilitates seamless interaction with care teams and proactive interventions based on early signs of health deterioration. 

A defining feature of INCA is its ability to integrate information beyond traditional electronic health records (EHR). The platform aggregates and harmonizes data from a wide array of sources that creates a holistic patient profile that captures the full context of an individual’s health and social circumstances, enabling more personalized and informed care planning.

Interoperability lies at the heart of INCA's design. The solution adheres to European Health Data Space principles, ensuring secure, high-speed data exchange across systems while maintaining robust privacy safeguards. Its open-source foundation and adherence to standards such as HL7 FHIR enable integration with diverse health information systems, ensuring scalability and flexibility across regional and national healthcare infrastructures. The integration of existing standards and APIs supports data continuity and enables providers to access comprehensive, real-time patient information, minimizing errors and duplication of efforts.

By centralizing patient data, enabling shared decision-making, and facilitating coordinated care delivery, INCA aims to address the inefficiencies of siloed healthcare models. The design aligns with the overarching goals of the CareMatrix Challenge by promoting a shift from reactive to proactive care while enhancing patient trust and engagement through personalized interventions.

Addressing clinical needs and supporting the CareMatrix Challenge

Multimorbid patients often navigate fragmented care pathways, leading to confusion, delayed interventions, and increased hospital readmissions. INCA addresses these challenges through its SCP, which consolidates all care activities into a unified framework accessible via the patient’s mobile app. For example, a patient managing diabetes, hypertension, and chronic kidney disease can use the app to track their medication regimen, monitor vital signs, and receive personalized recommendations based on their health status. INCA’s gamified tools incentivize adherence to prescribed treatments, while its alarm and alert systems provide early warnings of potential decompensation, allowing patients to proactively manage their conditions.

Healthcare professionals face significant administrative burdens and diagnostic complexities in managing PMM. INCA’s clinical decision-support system (CDSS) enhances efficiency by integrating tools such as DrugBank for medication reviews and AI-driven algorithms for risk stratification. For instance, a physician treating a multimorbid patient can use the platform to identify potential drug interactions, predict the patient’s risk of hospitalization, and adjust care plans dynamically in collaboration with other team members. This interdisciplinary approach is supported by the SCP, enabling real-time updates and communication across all care levels.

Assessing INCA’s impact and usability

To evaluate the potential of INCA to transform care for multimorbid patients, clinical testing will be conducted at three European sites: Region Skåne (Sweden), Vestre Viken (Norway), and Osakidetza (Spain). This phase, spanning February to June 2025, will focus on usability, functionality, and user experience in diverse healthcare settings. The testing will involve patients, caregivers, and healthcare professionals, aiming to capture how INCA meets the needs of all stakeholders.

The study will explore how INCA enhances care coordination, empowers patients through self-management tools, and reduces administrative burdens for providers. Participants will engage with the platform’s features, including its shared care plans, clinical decision-support tools, and multichannel communication capabilities. Feedback collected through surveys and focus groups will provide insights into usability, patient engagement, and workflow integration.

The outcomes will inform future development, ensuring alignment with user needs while building evidence for INCA’s readiness as a scalable solution. These tests will also generate data on how INCA could reduce clinical errors, improve care delivery, and enhance patient satisfaction, offering an early glimpse into its potential to redefine multimorbid care.

References

1.         Berntsen, G.K.R., et al., Person-centred, integrated and pro-active care for multi-morbid elderly with advanced care needs: a propensity score-matched controlled trial. BMC health services research, 2019. 19: p. 1-17.

2.         Grimsmo, A., et al., Disease-specific clinical pathways–are they feasible in primary care? A mixed-methods study.Scandinavian journal of primary health care, 2018. 36(2): p. 152-160.

3.         Melchiorre, M.G., et al., eHealth in integrated care programs for people with multimorbidity in Europe: Insights from the ICARE4EU project. Health policy, 2018. 122(1): p. 53-63.

4.         Marengoni, A., et al., Multimorbidity: epidemiology and models of care. BioMed research international, 2016. 2016.

5.         Wang, L., et al., A systematic review of cost-of-illness studies of multimorbidity. Applied health economics and health policy, 2018. 16: p. 15-29.

6.         Berntsen, G., et al., The evidence base for an ideal care pathway for frail multimorbid elderly: combined scoping and systematic intervention review. Journal of medical Internet research, 2019. 21(4): p. e12517.

7.         Palmer, K., et al., Multimorbidity care model: Recommendations from the consensus meeting of the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS). Health Policy, 2018. 122(1): p. 4-11.