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The Integrated Multimorbidity Care Model (IMCM), developed by the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS), proposes a set of 16 multidimensional components (i.e., recommendations) to improve the care of persons with multimorbidity in Europe. This study aimed at analyzing the potential applicability of the IMCM. We followed a qualitative approach that comprised two phases: (1) The design of a case study based on empirical clinical data, which consisted of a hypothetical woman with multimorbidity, type 2 diabetes mellitus, mental health, and associated social problems, and (2) the creation of a consensus group to gather the opinions of a multidisciplinary group of experts and consider the potential applicability of the IMCM to our case study. Experts described how care should be delivered to this patient according to each model component, suggested the use of specific rating scales and tools to assess her needs in a comprehensive and regular way, and pointed our crucial health and social resources to improve her care process. Experts also highlighted patient-centered, integrated and tailored care as one of the keystones of quality healthcare. Our results suggest that the IMCM is applicable in complex patients with multimorbidity. This publication derives from the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS), which has received funding from the European Union in the framework of the Health Programme 2008–2013. Sole responsibility lies with the author and the Consumers, Health, Agriculture and Food Executive Agency is not responsible for any use that may be made of the information contained therein. Sí

A Good Practice is a practice that works well, produces good results, and is recommended as a model. MACVIA-ARIA Sentinel Network (MASK), the new Allergic Rhinitis and its Impact on Asthma (ARIA) initiative, is an example of a Good Practice focusing on the implementation of multi-sectoral care pathways using emerging technologies with real life data in rhinitis and asthma multi-morbidity. The European Union Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS) has developed a checklist of 28 items for the evaluation of Good Practices. SUNFRAIL (Reference Sites Network for Prevention and Care of Frailty and Chronic Conditions in community dwelling persons of EU Countries), a European Union project, assessed whether MASK is in line with the 28 items of JA-CHRODIS. A short summary was proposed for each item and 18 experts, all members of ARIA and SUNFRAIL from 12 countries, assessed the 28 items using a Survey Monkey-based questionnaire. A visual analogue scale (VAS) from 0 (strongly disagree) to 100 (strongly agree) was used. Agreement equal or over 75% was observed for 14 items (50%). MASK is following the JA-CHRODIS recommendations for the evaluation of Good Practices., MACVIA-France., info:eu-repo/semantics/publishedVersion

Luciana Costa, researcher in the Department of Health Promotion and Prevention of Non-communicable diseases at the Portuguese National Institute of Health, presented the diabetes prevention and screening in vulnerable populations in Lisbon area. On 28 November, JA-CHRODIS organised a workshop at the European Parliament with the aim of presenting the Joint Action CHRODIS (EU Joint Action on Chronic Diseases and promoting healthy ageing across the life-cycle) to European policy makers. The workshop had a special focus to display the achievements in the field of diabetes prevention and management, and presenting the CHRODIS Platform. The event was hosted by MEP Therese Comodini Cachia (EPP), co-chair of the European Parliament Diabetes Working Group. Luciana Costa, researcher in the Department of Health Promotion and Prevention of Non-communicable diseases at the Portuguese National Institute of Health, presented the diabetes prevention and screening in vulnerable populations in Lisbon area. The objective of this intervention was to promote health in vulnerable communities in the Lisbon Metropolitan Area, especially to detect undiagnosed diabetes and individuals at high-risk of diabetes. The screening was carried out outside of the national health system. The FINDRISK questionnaire was used for interviews to detect undiagnosed diabetes and individuals at-risk (58% women and 42 % men; mean age 57 years). All activities, such as health promotion and diabetes prevention sessions for the general public and training for health and social professionals, were implemented within the community with strong support from municipalities, healthcare providers, local NGOs. Results showed that out of 11.712 people who carried out the risk assessment, 1.959 were identified as having high/very high risk of developing diabetes. In this group, around 20% of individuals had undiagnosed diabetes. The most valued factors for the population were both that awareness actions were free of charge and due to a close relationship with municipalities, healthcare providers and local NGOs, the stronger feeling of belonging to the community. According to Mr Bernal, this particular Portuguese good practice scores the highest among the evaluated practices submitted to the CHRODIS Platform. Responding to a question from the audience about the effect of the report received from the evaluators working behind the CHRODIS platform, Ms Costa said that they had their own evaluation process, yet an input from the experts outside of the system was very important to them. Joint Actions are a funding instrument under the third EU Health Programme 2014-2020. info:eu-repo/semantics/publishedVersion

Project CHRODIS - Work Package 5: Good practices in the field of health promotion and chronic disease prevention across the life cycle Associated Partners in the JA-CHRODIS Study Visit: National Health Institute Doutor Ricardo Jorge (INSA), Portugal (Luciana Costa) Report of JA-CHRODIS Study Visit - Iceland, under the Project CHRODIS - Work Package 5: Good practices in the field of health promotion and chronic disease prevention across the life cycle. The study visit in Iceland focused on the following two good practices: - The WELFARE WATCH, an intersectoral work aimed at vulnerable groups, transferred from National level (Iceland) to local level (the Sudurnes Region in Iceland) and international level (the Nordic Welfare Watch): - The NATIONAL CURRICULUM GUIDES ON HEALTH AND WELL-BEING as one of six fundamental pillars of education in Iceland, background and implementation. European Commission info:eu-repo/semantics/publishedVersion

Project CHRODIS - Work Package 5: Good practices in the field of health promotion and chronic disease prevention across the life cycle Associated Partners in the Joint Action on Chronic Diseases & Promoting Healthy Ageing across the Life CycleWORK PACKAGE 5: National Health Institute Doutor Ricardo Jorge (INSA), Portugal (Luciana Costa) Report of the meeting on identifying, assessing quality and presenting good practice interventions and policies, National Institute for Public Health and the Environment (RIVM), under the Project CHRODIS - Work Package 5: Good practices in the field of health promotion and chronic disease prevention across the life cycle. European Commission info:eu-repo/semantics/publishedVersion

Associated Partners in the Task 1: selecting JA-CHRODIS criteria to assess good practice in interventions related to chronic conditions: National Health Institute Doutor Ricardo Jorge (INSA), Portugal (Luciana Costa) The CHRODIS Delphi consultation gathered an expert panel to decide on the suitability and priority of a series of criteria to assess whether an intervention -policy, strategy, programme/service, as well as processes and practices- can be regarded as ‘good practice’ in the field of Health Promotion and Primary Prevention of Chronic Conditions. Following the RAND modified Delphi methodology, the consultation entailed two online rounds using a web-based questionnaire, followed by a face to face meeting. The number of participants was restricted to a maximum of 30 and a minimum of 15, allowing for eventual drop offs. The first web-based questionnaire included the criteria identified through a search and appraisal of primary and secondary documents from different sources. Two main bodies of information were identified. The first came from the country reviews conducted by JA-CHRODIS Work Package 5. The second was made up of the conceptual models, assessment tools, frameworks and procedures identified at national and international level for the evaluation of good practice related to chronic conditions, in particular -but not exclusively- those focused on health promotion and primary prevention. In addition, a reverse search was undertaken based on the identified and reviewed sources. The complete list of sources consulted and retained to elaborate the criteria is displayed in annex 1 and annex 2 includes the summary of the evidence compiled. The search for criteria was guided by the model depicted below, with a view to cover all those aspects of evaluation. European Commission N/A

Project CHRODIS - Work Package 5: Good practices in the field of health promotion and chronic disease prevention across the life cycle Associated Partners in the Work WP5 Task 5 – Study Visits to Assess Transferability. The Welfare Watch: National Health Institute Doutor Ricardo Jorge (INSA), Portugal (Luciana Costa) Report of study Visits to Assess Transferability - Icelandic Welfare Watch. The Welfare Watch, intersectoral work aimed at vulnerable groups, transferred from National level (Iceland) to local level (the Sudurnes Region in Iceland) and international level (the Nordic Welfare Watch). European Commission info:eu-repo/semantics/publishedVersion

Project CHRODIS - Work Package 5: Good practices in the field of health promotion and chronic disease prevention across the life cycle Associated Partners in the WP5 Task 5 – Study Visit @ JOGG, NL: National Health Institute Doutor Ricardo Jorge (INSA), Portugal (Luciana Costa) Report of study Visits to Assess Transferability: Netherlands: JOGG (Young people at healthy weight) under the Project CHRODIS - Work Package 5: Good practices in the field of health promotion and chronic disease prevention across the life cycle. European Commission info:eu-repo/semantics/publishedVersion

Project CHRODIS - Work Package 5: Good practices in the field of health promotion and chronic disease prevention across the life cycle Associated Partners in the Work WP5 Task 5 – Study Visits to Assess Transferability. National Curriculum Guides: National Health Institute Doutor Ricardo Jorge (INSA), Portugal (Luciana Costa) Report of study Visits to Assess Transferability: Icelandic national curriculum guides under the Project CHRODIS - Work Package 5: Good practices in the field of health promotion and chronic disease prevention across the life cycle. The National Curriculum Guides and Health and Wellbeing as one of six fundamental pillars of education in Iceland. European Commission info:eu-repo/semantics/publishedVersion