EGS+V (HMTE)– Health Management Team for Elderly: Implementation of an Integrated Case Management Model in the Elderly Population in Portugal

The EGS+V Model: Integrated Care for Multimorbidity and Aging

Accelerated population aging and the growing prevalence of multimorbidity (multiple chronic diseases) and polypharmacy (use of multiple medications) represent a structural challenge for the National Health Service (SNS) in Portugal. The country records high rates of emergency service use (more than double the OECD average), reflecting the fragmentation of care and the difficulty in coordinating the response across various levels.

 

Context: and MissionPortugal is one of the oldest countries in Europe, with projections showing that more than 30% of the population will be over 65 by 2050. Around 48% of this age group already has two or more chronic diseases, increasing clinical and therapeutic complexity. The Coimbra region, in particular, faces a high rate of elderly people with multimorbidity, leading to an increasing reliance on hospitals, multiple emergency visits, and avoidable hospitalizations.The Health Management Team for the Elderly and their Environment (EGS+V), created at ULS Coimbra, emerges as a response to this reality. Its objective is to develop and test a coordinated care model focused on elderly individuals with multiple chronic diseases, promoting effective integration between primary care, hospital care, and the community.

 

Approach: and StructureThe EGS+V model is based on a multidisciplinary intervention and inter-institutional co-creation (Primary Healthcare, Hospital Care, Community Pharmacies, Municipalities, and Parish Councils), fostering shared responsibility and territorial integration.The team is composed of doctors, nurses, social workers, and technical assistants. Inclusion criteria focus on complex patients: age over 70 years, more than 3 chronic diseases, 6 or more different medications, and high utilization of acute services (4+ emergency visits and/or 3+ hospitalizations in the last year).

 

Main Intervention Components: Home Assessment: Initial and semi-annual by a medical, nursing, and social team.Individual Health Plan: Co-constructed with the patient and caregiver, involving all professionals. Monitoring and Continuity: Through teleconsultation and remote monitoring. Community Connection: Social prescription to combat isolation and support therapeutic adherence in partnership with pharmacies. Alternatives to Inpatient Care: Direct connection to Home Hospitalization. Digital Support: Use of dashboards for proactive patient identification and real-time monitoring.

 

Preliminary Results and Implications: Preliminary results demonstrate significant gains in the management of complex patients and in system efficiency: Indicator Baseline EGS+V Target/Result Average Emergency Episodes/year4.5 Estimated 50% reduction / less than 2 for 75% of patients, Average Inpatient Episodes/year 3 estimated 50% reduction / less than 2 for 75% of patients. Economic Gains/patient-€3,338/year. Patient Satisfaction 4.1 to 4.5 (on a 1–5 scale)Therapeutic Adherence/Literacy more 70\% Environmental Impact Frequent, repetitive travel Reduction of carbon footprint more than 20\%.

 

The EGS+V model proves that care integration based on case management, interprofessional collaboration, and digital support can transform the response to multimorbidity. The lessons learned highlight the importance of coordinated teams, the value of social prescription, and the use of clinical data for continuous improvement.This model is replicable and scalable to other regions, aligned with SNS strategies and the WHO "Decade of Healthy Ageing 2021–2030" program, offering a path toward the sustainability, integration, and digitalization of healthcare.