RESEARCH FOR INNOVATION IN HEALTH SYSTEMS Improving the management of health care services for patients with multiple chronic conditions in three Latin American countries: Brazil, Colombia and Uruguay KEY MESSAGES Financial support BRAZIL Overview of multimorbidity The accelerated aging of the Brazilian Individuals with multimorbidity had a higher overall population, alongside the gradual increase in score in the Primary Health Care assessment (6.1 X 5.7), the concomitant occurrence of multiple chronic but below the cut-off point (6.6). diseases in the same individual, brings important Among individuals with multimorbidity, five challenges to the Brazilian National Health components of the PHC attributes presented scores System (SUS). ≥ 6.6: affiliation, first contact (use), longitudinality, coordination (care) and comprehensiveness (services Data from the National Health Survey 2019 provided). With the exception of the scores for first indicate that 29.5% of the Brazilian population contact (access) and coordination (information is multimorbid (has two or more chronic system), all others were significantly higher for diseases) and 45.2% report not having individuals with multimorbidity. any diseases. According to the Universidad Federal The most common chronic diseases de Minas Gerais (UFMG) database that are hypertension (23.9%), chronic back consolidates several existing information problems (21.6%), high cholesterol systems, the majority of health expenditure (14.6%) and depression (10.2%). by the Brazilian National Health System in the period between 2000-2015 was allocated Individuals without formal education to people with multimorbidity (52.88% of are those most frequently affected by expenditure). The greater the number of diseases, multimorbidity. The prevalence among those the greater the expenditure, with the total average without education is 44.8% and 25.7% among per capita expenditure being 1,742.99 (BRL – adjusted those with completed higher education. for the IPCA*) for people without chronic diseases and 97,831.03 (BRL - adjusted IPCA*) for people with five or The prevalence of multimorbidity is higher in more chronic diseases. women (35.4%) and increases with age for both sexes in the age group over 60 years old * BBRL - Adjusted IPCA: Price Index to the Adjusted Consumer in (above 50%). Brazilian Reals. Diagram of Venn for relationship between the four morbidities most prevalent among individuals aged 18 or older with multimorbidity. Brazil, 2019 Chronic back problem High cholesterol Individuals without formal education 10,3% 5,3% are the most Depression Hypertension frequently affected 5,7% 13,6% 2,4% by multimorbidity. The prevalence 7,9% 2,1% among those without 14,5% 3,1% 6,4% education is 44.8% 12,9% 6% and 25.7% among 2,4% 3,6% % those with completed 12,0 10,0 higher education. 8,0 3,8% 6,0 4,0 Source: National Health Survey 2019 - Brazil COLOMBIA Proposal for a comprehensive healthcare management model for people with multimorbidity and their caregivers Multimorbidity is a growing and increasingly visible Attention to multimorbidity in Colombia has global phenomenon due to population aging, to the been a scattered response from different actors physiological and emotional effects it causes, to the in the system who have answered the problems of high costs that its care generates for health systems, persons with multimorbidity. but above all due to the impact on the quality of life of those who live with it, their families, and their The model is a flexible and holistic proposal, focused caregivers. on the person and their environment, with a path that begins with the identification and stratification of In Colombia, during 2012 - 2016, the risk of those persons with multimorbidity multimorbidity had a prevalence of 19.5% in the space of a strengthened primary care. for all ages, according to data from It continues at other levels with other the study carried out by the World elements that complement healthcare, Bank and the Ministry of Health and such as physical activity, emotional Social Protection. The investigation support or appropriate nutrition, among also showed an increase in the use many others. and cost of health services associated with older age and the complexity of The proposed model is adaptable to multimorbidity, in an aging population the different health management and that shifts its epidemiological profile towards care realities of the country. However, it is chronic diseases. imperative to establish the household and primary care centers (PCC) as the appropriate settings for Nowadays, multimorbidity is one of the greatest the care and self-care of complex chronic cases. This challenges for health systems in all countries. It implies consolidating the patients’ connections, and requires innovations in the conception, organization, integrating the services into comprehensive care and management of health systems, in the training circuits organized in comprehensive and integrated and performance of human resources, in the health services networks, led by the PCCs within understanding of the person as a whole, in the a primary health care (PHC) framework under the prescription of medications, in interprofessional care, stewardship of the Territorial Health Entities and the and in quality of care. participation of community actors. More information Components of the multimorbidity care and management model. Proposal for a comprehensive healthcare management model for people with multimorbidity and their caregivers. Colombia 2022 The model is a flexible proposal, holistic, Strategic References focused in the person Component Definition Objectives and her surroundings, Subject population whose route starts at identification Tactical Strategies and stratification of Component risk of people with Approaches Attributes multimorbidity in the spaces of a primary Operational Management Care care strengthened. Component Resources Processes Results Source: The authors URUGUAY Proposal to optimize the care model for people with chronic diseases and multimorbidity The proposal is based on a process that included three demands 83% of the total expenditure and 87.3% of components: (i) stratification of the population with the total expenditure on medications for this subset Chronic Disease in Uruguay; (ii) study of care of patients for their care. models for Chronic Non-Communicable The definition of a minimum set of basic Disease (NCCD) and multimorbidity data widely used in all health information in Uruguay; and (iii) analysis of the systems - both in the public and private current situation and proposal to sectors - that record outpatient optimize the care model in Uruguay. production and the use of medicines, The stratification process of patients and their periodic transmission to health with NCCD according to their health policy makers is necessary to generate risk provides indicative results for periodic and reliable information aimed decision-making by health providers. at guiding public health policies. The expenditure with patients with The care model in the five selected multimorbidity in Uruguay is high. Persons highly prevalent Non-Communicable Chronic with five or more of diseases (Cardiovascular Disease, Diseases (NCDs) also presents ample room for High Blood Pressure, Diabetes, Chronic Obstructive improvement with respect to the extension in which Pulmonary Disease and Degenerative Neurological the specific components of the person-centered care Disease) represent 8.44% of the total patient model are applied; and in seeking and promoting the population, but their care accounts for 42.07% of the institutional development for the integration of care total expenditure, and 50.48% of the expenditure on teams that systematically identify multimorbidity and medications. apply common criteria for care and follow-up. If criteria of two or more hospitalizations during The optimization of care model is an effective strategy. the previous year and taking five or more different It takes into account the developments that have taken medications during the month are included, the place in the country and the availability of resources and percentage of patients with five or more of the processes, and proposes improvements based on the selected pathologies is reduced to 5.4% of the total gaps identified in relation to international models that number of patients with these characteristics, but it that seek to address the challenges of multimorbidity. Central elements of the model optimization proposal of attention. 2022 Self-care This is important, Periodic comprehensive assessment of the patient and their needs as the lack of Population stratification comprehensive care for these Specific models for chronic disease management patients represent Collaborative space between professionals a high individual Care units for the care of frail patients risk of serious chronic disease and Remote patient follow-up mortality, and a Creation of integrated PHC/hospital provider networks burden to families and society Support technology Cross-cutting focuses, oriented to quality of care and patient safety Source: The authors based on international experiences