General Objective:
MANAGE-CARE aims to prevent costly complications and frailty in elderly with type 2 diabetes, enabling them to live independent, healthy and active lives as long as possible. This will be achieved by driving innovation and change in the current treatment approach, shifting from diabetes management (disease-specific care trajectory) to chronic care management (non-disease focused model). A roadmap for implementation of the model will be developed, providing also guidelines for development of chronic care models in a broader context.

MANAGE-CARE aims to create a shift from disease management to chronic care management, in line with the second objective of the annual work plan to promote health, through change in care delivery and through partnering for change, addressing in particular older patients with multiple chronic conditions and using innovative business modelling. Diabetes will be used as a test-case for developing this innovative model, which coincides with the
Health Policy of the Danish Presidency focusing on chronic diseases with diabetes as a model disease. Prevention of costly complications, hospitalisation and frailty in elderly with chronic diseases is directly in line with the Implementation Plan of the EIP on active and healthy ageing, aiming at an increase in healthy life years and promoting healthy ageing. Patient empowerment and telemedicine, both mentioned in EIP which is supported by the 2012 public health work plan, constitute an important part in MANAGE-CARE as well.

Based on a state of the art assessment, providing knowledge and evidence on the existing disease management models and on the needs of older people with diabetes mellitus, a new chronic care model will be developed, driving change in the current treatment approach by shifting from disease management to chronic care management. Training programs for both health professionals and patients will be developed to work in accordance to this
model and ensure a patient-centred approach. Finally a toolkit for implementation of the new model and transfer of the model to other chronic diseases will be constructed. Desk research (literature, web) and surveys will be conducted; consensus building and use of expertise of key partners will be applied throughout the project.

By developing a new chronic care management model the project will contribute to improve the health of EU citizens. By working on wide implementation across the EU, MANAGE-CARE will help to reduce health inequalities between and within EU Member States, especially for older patients with chronic diseases. In addition, the project will build capacity for development and implementation of effective public health policies particularly in areas
of high need for the improvement of quality of care for patients with chronic diseases.
The MANAGE CARE project will lead to concrete outcomes for key stakeholder groups. More effective care and enhanced patient empowerment will lead to improved health and quality of life outcomes, enabling patients to stay independent, healthy and active. This in turn will reduce the burden on family members and other informal carers.
Improved cooperation and communication between health professionals and stakeholders who play a key role in chronic care management, clarity on new and shifting roles within the care team will lead to a better way of working.