A CIRCLE-CARE model in integrated care for patients with multimorbidity. An action research study

Purpose: This study aims to develop a model promoting integrated care for patients with multimorbidity based on patients’ and healthcare professionals’ needs to share knowledge in cross-sectoral communication and coordination in the local setting. Design/methodology/approach: We used an action research design that involved healthcare professionals, patients and researchers. The research followed an interactive process through its four phases. This study focuses on phase two, developing interventions to strengthen integrated care. The data consisted of audio recordings of workshops and field notes. Findings: An action research group and invited expert participants contributed to developing 25 proposals for improving cross-sectoral collaboration in integrated care. The fundamental principles were discussed among the action research group. Five key principles were identified to base the CIRCLE-CARE model: (1) collaboration, (2) involving patients and relatives, (3) relationships across sectors, (4) clear communication and (5) embrace knowledge. Originality/value: An action research group developed the CIRCLE-CARE model to address the needs of integrated care communication in the local context. The model is ready for future studies of its applicability, impact on patient pathways and healthcare costs.