Population is aging and the number of complex multimorbid patients to manage will increase sharply. Disease centred approach is not appropriate to manage these patients. Change to a patient-centred approach will simplify care pathways, secure management and treatment decision making and decrease healthcare costs. It will be a real breakthrough for daily practice with multiple impacts that must be quantified.

GerOnTe multimorbid patient-centred system proposes:

1) Coordination of management by a patient-tailored, interdisciplinary health professional consortium (HPC), including hospital- and home-based professionals, with a case manager;

2) Timely registration of symptoms and patient-reported outcomes at home through a web-based app for anticipation of avoidable adverse events;

3) Proposal of self-management guidelines according to intrinsic capacity evaluation by geriatrician for patient-driven improvement of independent living;

4) Structured collection of data from electronic health record into a dashboard made available to HPC members as well as patient and caregiver, thanks to its capacity to securely interoperate with all electronic health records including software managing medical data. The whole approach will be co-designed with patients, informal care givers and health professionals.

Cancer is an excellent model to develop this approach in multimorbid patients because it is frequent and commonly associated with other morbidities in older patients but also because of its major impact on patients’ general status and coexistent diseases. Cancer already benefits from a multidisciplinary management model that GerOnTe will enhance, strengthening exchange of holistic data, role of primary care and case management. GerOnTe will also provide new country-specific guidelines and best practices for implementation across Europe and for improved management of older multimorbid patients including improved quality of life and independent living at decreased costs.

This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 945218.

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