Challenges C3-Cloud is tackling

Multimorbidity

Finding the best way to support and treat people with multimorbidity, the occurrence of two or more long-term health conditions, can be challenging. Not only are patients and their informal carers struggling to manage daily health requirements; the clinical management of multimorbid patients is much more complex and time-consuming than those with single diseases. Achieving good quality integrated care is an acknowledged difficulty in many health systems.

Multimorbid patients experience shortcomings and gaps in care provision, especially at the interfaces within and between health and social care delivery organisations.

%

of people aged 65 and over are estimated to live with multimorbidity (1)

Clinical guidelines

Clinical guidelines for how best to treat conditions and the ways in which healthcare teams are organised are often designed for caring for individual health problems, but not a combination. Different health conditions, and treatments for different health conditions may interfere with one another. For example, a person with diabetes and renal disease might be advised by their healthcare professionals to follow two conflicting food diets; one focused on managing diabetes and another on managing kidney problems. Therefore C3-Cloud has integrated Clinical Decision Support Services.

 

Clinical practice guidelines are currently single disease centred, and often fall short to organise care for patients with multimorbidity.
Polypharmacy

A special challenge in caring for patients with multiple health conditions is that they often need to take multiple medications, the situation known as polypharmacy. There is a risk that the side-effects of one medicine could exacerbate another condition which the patient has, and so special care is needed to manage multiple medications. It is essential that all of the clinical teams caring for multiple conditions of the patient are aware of each other’s prescribing. More info how C3-Cloud can assist clinicians dealing with polypharmacy.

%

of hospitalised frail older patients were found to have been discharged on at least one unnecessary medication (2)

Personalised and integrated care planning

As the number and complexity of health conditions increase over time, the type and number of care providers contributing to the care of individuals also increases. It becomes significantly more difficult to align and coordinate care across care teams and care settings. This results in specialty silos and fragmented care, due to poor communication and information sharing. Without secure information exchange among the actors involved in health, social and informal care services and a process to reconcile potentially conflicting treatment plans, it is impossible to avoid redundant and potentially harmful interventions. C3-Cloud’s Coordinated care & cure delivery platform assists the multidisciplinary care team members to create personalised and integrated care plans.

 

C3-Cloud helps avoid fragmented, redundant and potentially harmful interventions.

 

Patient empowerment

Studies have shown that activated patients have better health outcomes and better care experiences than patients who are less activated (3) (4) (5) (6) (7). C3-Cloud aims to give the patient and their informal caregivers a voice in the management of their own care and ensure their active participation in the management of patient’s multi-morbid chronic conditions. Discover the Patient Empowerment Platform.

“Yes, quality of care in past year was excellent or very good” (7)
  • Engaged patients 69% 69%
  • Not engaged patients 42% 42%
C3-Cloud enables the development of personalised care plans for multimorbid conditions by a group of collaborating health and social care givers with the support of clinical decision support services automating evidence based clinical guidelines, and guideline reconciliation rules including drug-drug, drug-disease, disease-disease interactions.

(1) Onder G, et al. Time to face the challenge of multimorbidity. A European perspective from the joint action on chronic diseases and promoting healthy ageing across the life cycle (JA-CHRODIS). European Journal of Internal Medicine. 2015;26(3):157–159

(2) Unnecessary drug use in frail older people at hospital discharge. Hajjar ER, Hanlon JT, Sloane RJ, Lindblad CI, Pieper CF, Ruby CM, Branch LC, Schmader KE J Am Geriatr Soc. 2005 Sep; 53(9):1518-23.

(3) Hibbard JH, Stockard J, Mahoney ER, Tusler MDevelopment of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumersHealth Serv Res2004;39 (4 Pt 1): 1005 – 26 . Crossref, Medline, Google Scholar

(4) Mosen DM, Schmittdiel J, Hibbard J, Sobel D, Remmers C, Bellows JIs patient activation associated with outcomes of care for adults with chronic conditions? J Ambul Care Manage2007;30 (1):21–9. CrossrefMedline, Google Scholar

(5) Remmers C, Hibbard J, Mosen DM, Wagenfield M, Hoye RE, Jones C. Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes? J Ambul Care Manage. 2009;32 (4): 320-7. Crossref, Medline, Google Scholar

(6) Skolasky RL, Mackenzie EJ, Wegener ST, Riley LH. Patient activation and functional recovery in persons undergoing spine surgery. Orthopedics. 2011;34 (11): 888. Crossref, Medline, Google Scholar

(7) Osborn R, Squires D. International perspectives on patient engagement: results from the 2011 Commonwealth Fund survey. J Ambul Care Manage. 2012 ; 35 (2): 118 – 28