OPTimized eHealth for Individuals with Multi-morbidity And Long-term needs – OPTIMAL

Nedlastbar poster


Persons with multiple long-term conditions (multi-LTC) typically face multiple care processes, specialties and organizations over longer periods. Current care often meet their needs poorly, due to a profession centric, re-active and fragmented design.(1) See fig 1.

Aim: To develop a care generic care model for persons with multi-morbidity and / or long-term, complex care needs.


We combined knowledge from:

  • Patient experiences
  • Health professional experiences
  • Literature review

We added

  • Feedback from a broad spectrum of stakeholders.
  • Service re-design + implementation of “active ingredients.
  • Effect studies of the resulting intervention.


The core-product of healthcare is the individualized patient pathway.

Active ingredients of OPTIMAL care (see fig 2).

A person-centered approach:

  1. The patient pathway produces value, when it meets the patient’s goals.
  2. Goals formulation starts with the person’s answer to: “What matters to me?”
  3. “What matters” to the patient, is translated into relevant and realistic goals for care in a negotiation process.
  4. Patient driven evaluation and adjustment of plans, in alignment with goals

Integrated care

recruitment of the team that holds the core set of competencies needed to cover the goals set for the pathway.

A planned and proactive

a) support for self-management/

b) linkage to community resources

c) plans for evidence-based elective and emergency care and

Digitally leveraged

  1. A virtual team environment that supports (a)synchronous dialogue to share, develop and update the care-plan.
  2. Digitally optimized service-resource planning for plan implementation.
  3. Pro-active remote follow-up in the home-environment for support of care delivery and early detection of preventable undesired events.


The OPTIMAL care model will fit both the most complex multi-LTC and the simplest episodic single disease pathway.

It requires e-Health, regulatory, economic and professional settings to recognize the personalized goal oriented pathway as health-care’s core product.


1.Tinetti ME, Fried T, Boyd C. DEsigning health care for the most common chronic condition—multimorbidity. JAMA: the journal of the American Medical Association. 2012;307(23):2493-4.