From fragmented care to integrated, person-centred and digitally supported care
Summary
The complex multimorbid patient is someone living with multiple chronic conditions (usually ≥2 or ≥3) that interact with one another, often combined with polypharmacy, frailty, psychosocial problems and/or limited health literacy. In Belgium this affects nearly half of the population aged 15 and over.
According to the recent Health Interview Survey by Sciensano (2023-2024), 48 % of people aged 15+ have at least two chronic conditions. Among those aged 75 and over the figure rises to 76 %. The sharpest increase in recent years has been in the working-age group 25-64. Multimorbidity is more common among women and people with lower educational attainment. People with multimorbidity account for roughly three-quarters of total healthcare expenditure.
Belgium’s healthcare system, with its federal and regional competences, fee-for-service model and strong separation between primary and secondary care, has historically been organised around acute and single-disease care. This results in fragmentation, loss of overview, polypharmacy and a high treatment burden.
This thesis describes the Belgian epidemiology, existing initiatives (Common Plan for Chronic Care, interfederal plan for integrated care, care pathways, case-management pilots and projects such as I-CONNECT) and introduces the 2.0 approach: complexity science, person-centred shared decision-making, case management, eHealth support and population-oriented integrated care.
Chapter 1 – Introduction and problem statement
Multimorbidity is not a simple addition of diseases, but a complex adaptive system in which conditions, medication, functioning and social context continuously influence one another.
Belgian healthcare organisation has historically been built around acute illness and monodisciplinary specialisms. Rising multimorbidity collides with this structure. Patients often see multiple specialists and GPs without structural coordination. Guidelines are mostly disease-specific and take insufficient account of interactions.
The central question: how can Belgian care for the complex multimorbid patient evolve from fragmented and supply-driven to integrated, person-centred and digitally supported (2.0)?
Chapter 2 – Definition, epidemiology and characteristics in Belgium
Definition
Multimorbidity = presence of at least two chronic conditions.
Complex multimorbidity = ≥3 conditions in different organ systems, often with polypharmacy, combined somatic and mental health problems, frailty and social factors.
Belgian figures (Sciensano HIS 2023-2024)
- 48 % of people aged 15+ have ≥2 chronic conditions.
- 76 % among those aged 75+.
- Strongest rise in the 25-64 age group.
- More common in women (54 %) than men (42 %).
- Clear socio-economic gradient: lower-educated people have 1.3 times higher risk.
- Regions: Flanders ±48.7 %, Wallonia ±50.4 %, Brussels significantly lower (±37.7 %).
Most frequent combinations
Arthropathies (joint conditions such as osteoarthritis or arthritis) + dorsopathies (back and neck problems such as chronic back or neck pain); dorsopathies + allergy (hypersensitivity reactions such as hay fever or house-dust-mite allergy); and triads including hypertension.
Circulatory conditions (heart and vascular diseases such as heart failure, arrhythmias or vascular problems) and musculoskeletal conditions (problems of muscles, bones and joints such as osteoarthritis, rheumatism or chronic back complaints) form the largest clusters.
Impact
Higher care costs (COMORB study), lower quality of life, more functional limitations, higher mortality and a disproportionately large share of total health expenditure.
Chapter 3 – Challenges in Belgian care
- Institutional fragmentation between federal level (RIZIV/INAMI, nomenclature) and regions (care organisation, welfare).
- Fee-for-service rewards volume rather than coordination and prevention.
- Limited integration between primary and secondary care, and still limited role for nurses in general practice.
- Disease-specific care pathways (diabetes, chronic kidney disease) that take insufficient account of multimorbidity.
- Data and information problems: despite eHealth and the Global Medical Record (GMD), overview is often lacking.
- Patient and informal-carer perspective: loss of control, high treatment burden and unequal access.
Chapter 4 – Existing Belgian initiatives and frameworks
Common Plan “Integrated Care for Better Health” (2015) and the Interfederal Plan for Integrated Care (protocol agreement 2023).
- Twelve loco-regional pilot projects for integrated care.
- Care pathways and the RIZIV status for chronic conditions.
- Pathology-specific case-management pilots (including ALS, Huntington’s, MS, Parkinson’s).
- Research projects such as I-CONNECT (KU Leuven et al.): integrated care for community-dwelling older people with depression and physical multimorbidity (care coordinator, medication review, multidisciplinary collaboration).
- KCE reports on chronic care and system performance.
- Domus Medica and SSMG work on primary-care organisation and multidisciplinary collaboration.
These initiatives lay the foundations but are still insufficiently scaled up and insufficiently tailored to complex multimorbidity.
Chapter 5 – The Complex Multimorbid Patient 2.0 in the Belgian context
The 2.0 approach combines:
- Complexity science: non-linear interactions, emergence and co-evolution of health problems.
- Person-centredness: “What matters to you?” as starting point, shared decision-making and an individual care plan.
- Case management and care coordination: independent case managers or care coordinators working across lines and sectors (extension of existing pilots).
- Digital support 2.0: optimal use of eHealth, GMD, shared care plans, medication surveillance and (cautiously) AI/network analyses of comorbidity patterns.
- Team-based and population-oriented care: strengthening general practice (with nurses), Primary Care Zones (Flanders), interprofessional collaboration and transitional care from hospital to home.
- Minimally disruptive care: reducing treatment burden, aligning appointments and stopping unnecessary checks.
Belgian 2.0 elements are already visible in I-CONNECT, the case-management pilots and the interfederal plans, but require further scaling, structural funding and training.
Chapter 6 – Recommendations for Belgium
- Recognition: systematic identification of complex multimorbidity in general practice and by specialists (number of conditions, polypharmacy, frequent acute care, frailty, socio-economic factors).
- Comprehensive assessment: biopsychosocial, functional, medication and patient preferences.
- Scaling of case management and care coordination for highly complex patients, independent of pathology-specific silos.
- Strengthening interfederal collaboration and alignment of financing (less pure fee-for-service, more incentives for coordination and quality).
- Digital infrastructure: further development of shared care records, real-time overview and AI-supported medication and interaction alerts, with attention to digital inequality.
- Education: complexity thinking, shared decision-making in multimorbidity and interprofessional working in basic and postgraduate training.
- Research: evaluation of Belgian 2.0 models (cluster RCTs, implementation research), validation of comorbidity networks on Belgian data (IMA-AIM, Sciensano) and monitoring of treatment burden and patient-reported outcomes.
Conclusion
The complex multimorbid patient is no longer an exception in Belgium but the reality for nearly half of the adult population. The current, still strongly fragmented organisation is unsustainable.
The 2.0 approach, grounded in complexity science, person-centredness, structural care coordination, eHealth and interfederal collaboration, offers a realistic framework to make care future-proof. Existing plans, pilots and research projects form a solid base. What is now needed is consistent scaling, adapted financing and a culture shift from disease-oriented to person- and population-oriented care.
Only then can Belgian patients with complex multimorbidity retain control, reduce treatment burden and achieve better outcomes.
This thesis is a synthesising overview based on Belgian sources (Sciensano, KCE, IMA-AIM, interfederal plans, I-CONNECT and related projects) up to mid-2026. It is intended as a framework for further research, policy and practice development in the Belgian context.
