1. Characterisation and implications of chronicity
- The epidemiology of chronic diseases. Multimorbidity, including its definition, determining factors, prevalence, early identification, inter-relations and evolution.
- Stratification models and their use to predict needs and adapt resources for chronic patients.
- The population-based burden of chronic diseases. Healthcare, social, financial and economic implications, including disability, quality of life, patient safety, sustainability of the system and others.
- Equality in health and chronicity strategies, characterisation and monitoring of inequalities in the access, use, quality and results, explanatory factors and evaluation of interventions.
2. The health services required to manage chronicity
- Evaluation of healthcare services, including economic evaluation, and identification of factors affecting the management of chronicity, with a common framework that includes both social and healthcare aspects.
- Health-promotion strategies, including individual and structural actions and community health action models.
- The design of personalised care (care management for high-risk patients, integrated care for chronic patients, multidisciplinary collaborative programs).
- The most appropriate service and management models for chronicity, including funding, service contracting, integrated care systems, technologies or new professional roles.
- Advanced decision-making strategies and methods, organisational transformation and innovation, including research into the development of new healthcare products and technologies.
3. Design of new intervention models and tools
- Models for promoting self-care (patient responsibility, active patient, role of social networks) and community participation.
- Knowledge management and decision-making support applications, techniques, devices, networks, software, algorithms, processes and guidelines.
- e-Health (diagnosis, care, monitoring, coordination).
- Adaptation of traditional epidemiological tools to the study of chronic diseases and the development of new tools, their application for evaluating the effectiveness and efficiency of new interventions, technologies and services.
- The development of research methodologies for chronicity-related care models, the innovation and standardisation of effective and efficient interventions.