Personalised Care Planning

Multi-morbidity creates diverse and sometimes contradictory needs which challenge patients and the delivery of health services [1]. The clinical management of patients with multi-morbidity is much more complex and time-consuming than those with single diseases [2]. Currently those with chronic conditions and long-term care needs experience shortcomings and gaps in care provision. This is particularly prominent at the interfaces within and between health and social care delivery organisations [3]. Achieving good quality integrated care is an acknowledged difficulty in many health systems.


 As the number and complexity of health conditions increase over time and episodes of acute illness are superimposed, 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.


 Current European medical models (e.g. as directed by clinical guidelines) focus primarily on short and medium term interventions on the basis of single conditions, failing to integrate care planning well across providers and often overlooking the interconnected basis of chronic diseases. Clinical guidelines, which re-factor the best available published evidence on clinical effectiveness into decision trees and care pathways, and which are increasingly multi-professional and work across care providers, almost always focus on treating a single disease. Clinical guidelines may clash (e.g., due to incompatible treatment and monitoring regimes). Following more than one clinical guideline can result in inefficiencies for the patient and for the health system due to duplicating and inconveniently scheduled investigations and clinic visits and, more importantly, treatments that may exacerbate another condition [4]. For example, when US guidelines for chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis were examined, only one of the five explicitly acknowledged potential multi-morbidity, with the recommendations being sometimes contradictory and implying a drug and self-care regimen that would be unfeasible for many patients [5]. Similar problems apply to National Institute for Health and Clinical Excellence (NICE) guidelines in the UK [6].


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[1] Piette, J., Richardson, C. and Valenstein, M. (2004) Addressing the needs of patients with multiple chronic illnesses: the case of diabetes and depression, Am J Manage Care, 10: 152–62.

[2] Australian Institute of Health and Welfare, Comorbidity of cardiovascular disease, diabetes and chronic kidney disease in Australia, August 2007

[3] European Innovation Partnership on Active and Healthy Ageing, Action Plan on ‘Replicating and tutoring integrated care for chronic diseases, including remote monitoring at regional levels’.

[4] Guthrie, B., Payne, K., Alderson, P., McMurdo, M.E.T., and Mercer, S.W. (2012) Adapting clinical guidelines to take account of multimorbidity. British Medical Journal, 345 (oct04 ). e6341-e6341. ISSN 0959-535X (doi:10.1136/bmj.e6341)

[5] Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294(6):716.

[6] Hughes L, McMurdo MET, Guthrie B. Guidelines for people not for diseases: the challenges of applying UK clinical guidelines to people with multimorbidity. Age Ageing. 2013 Jan;42(1):62-9.

Managing multi morbidity, through the current treatment methods, results in specialty silos and fragmented care, involving multiple health and social care providers who are not effectively communicating and sharing information.

Traditionally, the adoption of clinical practice guidelines has been promoted for managing chronic conditions. However clinical practice guidelines are currently single disease centred, and often fall short to organise care for patients with multi morbidity.

C3-Cloud enables the development of personalised care plans for multi-morbid 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. The most recent EHRs of the patient are collected from the local care sites and automatically processed by clinical decision support systems to propose personalized care plan gola and activity suggestions to the care team members.