Ageing of the population together with changes in lifestyle are central factors to explain the increasing prevalence of chronic disorders, which is expected to continue over the next decades leading to further dysfunctions of healthcare systems worldwide. The urgent need for introducing substantial changes in delivery of care for chronic patients is widely accepted. The basic principles and strategies to enhance management of chronic patients have been disseminated since early this century by the WHO.
Although limited published data exist evaluating the efficacy of the chronic care model, different pilot experiences on integrated care programs have shown positive results indicating the potential of home-based integrated care to enhance clinical outcomes while generating cost-containment at system level. However, a common problem in all these pilot studies is that disease-specific trials have shown high internal validity, but a questionable external validity because of an elevated rate of exclusions. It must be taken into account that approximately 60% of exclusions are generally due to severe co-morbid conditions that could be potentially managed through transversal programs addressed to frail patients with multiple severe chronic disorders. The second most important exclusion factor, often present in frail patients, is lack of appropriate community resources which reinforces the need for bridging healthcare and community services providing social support.
There is a need to move the focus from the current interest in advanced chronic conditions toward the development of preventive integrated care strategies addressed to early stages of chronic diseases or even to citizens with an increased risk of developing chronic disorders. Ultimate aims should include enhancement of efficiencies of management aspects and positive modulation of the prognosis of chronic disorders. To face all these challenges, increasing attention is being paid to the need for deep organizational changes of health systems from a provider-centered perspective to a patient-focused approach. In the new scenario, a major issue will be the extensive introduction of information and communication technologies (ICT) as enabling tools to facilitate new ways of accessibility of citizens to the system, to effectively promote information sharing among professionals across the system and between citizens and both formal and informal care givers. Altogether these changes should have a marked positive impact on standardization of procedures. While acknowledging the central role of primary care in chronic care management, we raise the strategic need for a proper interface between hospital care and primary care. We learnt that co-morbidity plays a major role on unplanned admissions and it constitutes a limiting factor for the deployment of disease-specific programs. The design of patient-oriented guidelines across chronic conditions that are often clustered is strongly needed to develop well standardized preventive programs.