The development of a care model falls into the larger scope of the Chair’s approach to evaluating clinical practices with regard to chronic disease. Under this theme, the descriptive data collected, knowledge on patients, families and primary care workers’ experiences as well as the theoretical basis acquired, will serve as the building blocks for the development and evaluation of innovative interventions involving interprofessional collaborations, in particular between physicians and nurses working with patients presenting multiple chronic diseases.
The World Health Organization’s Innovative Care for Chronic Conditions framework will serve as the theoretical foundation for the development of this intervention. The physician-nurse collaboration in family medicine groups is a key component offering a unique opportunity for the interdisciplinary management of patients with multiple problems.
This theme will include the development of pilot projects essentially aimed at developing an intervention program based on interdisciplinary collaboration for the management and follow-up in primary care of patients with multiple chronic conditions. The collaboration of concerned actors (patients, families, primary care professionals, decision-makers) will allow us to describe the development and implementation processes of the intervention program; to evaluate the effects of the program on continuity of care, quality of care, therapeutic compliance and costs; to evaluate the effects of the program on the stability and control of medical conditions, as well as on quality of life, self-care behaviour, feeling of competency and satisfaction with regard to care received.