On 9 October the conference “Collaborative Approach to Multimorbid Patients in Osakidetza, developed under the European Project ACT@Scale” was held at the Auditorium of the Cruces University Hospital.
The aim of Act@Scale European project is to implement, develop and consolidate Good Practices in Integrated Care and Telemonitoring, to promote scaling up and transfer of lessons learnt and knowledge to other European regions. Kronikgune and Osakidetza participate with two good practices: telemonitoring for patients with heart failure and the integrated intervention programme for multimorbid patients or healthcare pathway for multimorbid patients.
The aim of this event was to present the healthcare pathway for multimorbid patients to the Basque health service (Osakidetza) professionals and managers. The progressive implementation of this pathway in Osakidetza organisations was also discussed.
The healthcare pathway for multimorbid patients is defined taking into account the aims to be achieved, the target patients, the activity sequence, the professionals who need to participate as well as its coordination and assessment. It also includes the patient empowering process, using the Kronikon programme. This pathway has the digital support of Osabide’s Integral Programme Manager.
The work carried out in the healthcare pathway for multimorbid patients under the ACT@SCALE project started in 2016 through a collaborative methodology where all Osakidetza service organisations have participated.