A conceptual model to manage multiple chronic conditions based on PDSA theory

Background: The increasing prevalence of comorbidities poses a significant challenge to population health management. The World Health Organization (WHO) suggests that an integrated care model relieves the pressure of healthcare management on people with multimorbidity. Objective: We constructed a conceptual model to manage multiple chronic conditions based on PDSA theory, consisting of four key elements: management team, proceedings, tools, and performance. Result: The model merges patient-centered care, multidisciplinary team, self-management, and other intervention methods mentioned in previous research. Meanwhile, we rely on big data to set up a decision support platform to realize the whole life cycle health management of comorbid patients.