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Background <p>Due to the high impact on an individual’s quality of life and the enormous pressure on health and social services, the increasing prevalence of multimorbidity in the elderly population is becoming a public health priority and a shared global challenge. However, a gap exists between clinical recommendations suggesting the setting up of multidisciplinary and multiprofessional teams for the management of multimorbidity and how to feasibly translate this recommendation into routine clinical practice. In particular, the purpose of this article is to describe an Italian pilot study that tested the feasibility of teleconsultation to facilitate the creation of and communication between multiprofessional and multidisciplinary teams. The teams consisted of General Practitioners, Nurses and Specialists.</p> Methods <p>In the framework of the European Joint Action JADECARE, the Health Regional Agency of Tuscany designed a pilot study for the care of patients suffering from multimorbidity implemented through the Plan-Do-Study-Act methodology in the Piana di Lucca District Zone. The pilot consisted of an initial phase of enrollment, a multidimensional assessment, a synchronous teleconsultation aimed at sharing and discussing Individual Care Plans by multiprofessional and multidisciplinary teams and a proactive follow-up. The feasibility of the study was analyzed by monitoring the achievement of Key Performance Indicators, while the execution of some specific activities and the possible added value of teleconsultation for improving care of patients suffering from multimorbidity were evaluated through a mixed-method approach. In particular, three surveys and focus groups were addressed to the professionals involved in the study.</p> Results <p>From August 2022 to January 2023 the professionals performed 36 multidimensional assessments, carried out 36 teleconsultations and performed 33 first follow-ups. From professionals’ perspective, teleconsultation produced benefits in terms of therapeutic safety and a reduced risk of urgent specialist visits and unscheduled admissions to hospital acute ward for most patients. It reduced the risk of Emergency Room (ER) access but only for specific cases. The perceived utility of teleconsultation has an average value of 8, ranging from 1 (useless) to 10 (extremely useful).</p> Conclusions <p>The pilot study showed the feasibility in routine clinical practice of using synchronous teleconsultation to foster the creation of and communication between multiprofessional and multidisciplinary care teams. The professionals involved highlighted the general usefulness of teleconsultation, which could contribute to better health outcomes for patients suffering from multimorbidity.</p>

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Multiprofessional and multidisciplinary teleconsultation for the management of multimorbidity: preliminary results from the joint action JADECARE

  • 期刊论文

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  • 发表日期：

    2026年4月18日

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  • Chiara Ferravante,
  • Martina Rimmele,
  • Zdenek Gütter

摘要

Background

Due to the high impact on an individual’s quality of life and the enormous pressure on health and social services, the increasing prevalence of multimorbidity in the elderly population is becoming a public health priority and a shared global challenge. However, a gap exists between clinical recommendations suggesting the setting up of multidisciplinary and multiprofessional teams for the management of multimorbidity and how to feasibly translate this recommendation into routine clinical practice. In particular, the purpose of this article is to describe an Italian pilot study that tested the feasibility of teleconsultation to facilitate the creation of and communication between multiprofessional and multidisciplinary teams. The teams consisted of General Practitioners, Nurses and Specialists.

Methods

In the framework of the European Joint Action JADECARE, the Health Regional Agency of Tuscany designed a pilot study for the care of patients suffering from multimorbidity implemented through the Plan-Do-Study-Act methodology in the Piana di Lucca District Zone. The pilot consisted of an initial phase of enrollment, a multidimensional assessment, a synchronous teleconsultation aimed at sharing and discussing Individual Care Plans by multiprofessional and multidisciplinary teams and a proactive follow-up. The feasibility of the study was analyzed by monitoring the achievement of Key Performance Indicators, while the execution of some specific activities and the possible added value of teleconsultation for improving care of patients suffering from multimorbidity were evaluated through a mixed-method approach. In particular, three surveys and focus groups were addressed to the professionals involved in the study.

Results

From August 2022 to January 2023 the professionals performed 36 multidimensional assessments, carried out 36 teleconsultations and performed 33 first follow-ups. From professionals’ perspective, teleconsultation produced benefits in terms of therapeutic safety and a reduced risk of urgent specialist visits and unscheduled admissions to hospital acute ward for most patients. It reduced the risk of Emergency Room (ER) access but only for specific cases. The perceived utility of teleconsultation has an average value of 8, ranging from 1 (useless) to 10 (extremely useful).

Conclusions

The pilot study showed the feasibility in routine clinical practice of using synchronous teleconsultation to foster the creation of and communication between multiprofessional and multidisciplinary care teams. The professionals involved highlighted the general usefulness of teleconsultation, which could contribute to better health outcomes for patients suffering from multimorbidity.