Description du projet
Une approche centrée sur le patient pour les patients multimorbides
Le vieillissement de la population se traduit par un nombre croissant de cas complexes de patients chroniques multimorbides nécessitant un soutien médical. Par conséquent, la médecine moderne exige une attitude nouvelle, centrée sur le patient, pour des options de traitement plus efficaces, ainsi que pour une réduction des coûts et une meilleure prise de décision. Le projet GERONTE, financé par l’UE, combinera l’expertise en matière de santé publique et de transformation numérique du secteur public afin d’exploiter la technologie numérique pour améliorer les résultats des soins de santé des patients âgés présentant des comorbidités. En s’appuyant sur le modèle de la prise en charge pluridisciplinaire du cancer, il coélaborera avec les patients, les aidants et les professionnels une approche adaptée aux patients qui facilitera les parcours de soins, la prise en charge et les décisions relatives au traitement, tout en réduisant les coûts liés aux soins de santé.
Objectif
Population is aging and the number of complex multimorbid patients to manage will increase sharply. Disease-centred approach is not appropriate to manage these patients. Change to a patient-centred approach will simplify care pathways, secure management and treatment decision making and decrease healthcare costs. It will be a real breakthrough for daily practice with multiple impacts that must be quantified. GERONTE multimorbid patient-centred system proposes:
1) Coordination of management by a patient-tailored, interdisciplinary health professional consortium (HPC), including hospital- and home-based professionals, with a case manager;
2) Timely registration of symptoms and patient-reported outcomes at home through a web-based app for anticipation of avoidable adverse events;
3) Proposal of self-management guidelines according to intrinsic capacity evaluation by geriatrician for patient-driven improvement of independent living;
4) Structured collection of data from electronic health record into a dashboard made available to HPC members as well as patient and caregiver, thanks to its capacity to securely interoperate with all electronic health records including software managing medical data.
The whole approach will be co-designed with patients, informal care givers and health professionals.
Cancer is an excellent model to develop this approach in multimorbid patients because it is frequent and commonly associated with other morbidities in older patients but also because of its major impact on patients’ general status and coexistent diseases. Cancer already benefits from a multidisciplinary management model that GERONTE will enhance, strengthening exchange of holistic data, role of primary care and case management.
GERONTE will also provide new country-specific guidelines and best practices for implementation across Europe and for improved management of older multimorbid patients including improved quality of life and independent living at decreased costs.
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RIA - Research and Innovation actionCoordinateur
33000 Bordeaux
France