{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T18:17:00Z","timestamp":1788373020718,"version":"build-2803163510"},"reference-count":53,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T00:00:00Z","timestamp":1788307200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:p>Multimorbidity the coexistence of two or more chronic conditions is a growing challenge for health systems in low- and middle-income countries (LMICs) structured around single-disease paradigms. In Colombia, insurer\u2013provider fragmentation within the General System of Social Security in Health (SGSSS) compounds this challenge, generating discontinuities in care that disproportionately affect people living with multiple chronic conditions. Despite a national epidemiological characterisation, a World Bank-supported management proposal, and a formal pilot implementation, limited published evidence exists of a sustained, provider-level, evidence-grounded model for multimorbidity care in fragmented, insurance-based systems. A sequential exploratory mixed-methods design was employed, comprising three phases: (1) a structured evidence synthesis to identify operational domains and implementation gaps in multimorbidity care models; (2) evidence-informed conceptual model construction; and (3) expert feasibility consultation using elements of the Nominal Group Technique with healthcare professionals and system stakeholders (n\u2009=\u200911). Phases were sequentially integrated, with each informing the development of the next. Evidence synthesis identified five recurring structural domains and four cross-cutting implementation gaps, which together informed the construction of the Integrated Provider-level Adaptive Multimorbidity Model (IPAM). The IPAM comprises five interdependent provider-level components designed to function within fragmented, insurance-based systems. Expert consultation confirmed operational feasibility (mean 4.3\/5), clinical relevance (4.7\/5), and territorial adaptability (4.6\/5) of the proposed model. The IPAM offers a structured, adaptable conceptual framework for strengthening multimorbidity care within provider institutions (IPS) operating in fragmented, insurance-based health systems. Its core design principles minimum-viable risk stratification, provider-level governance, proactive follow-up, and graduated technology integration \u2014 are transferable to analogous LMIC contexts. Prospective implementation and cost-effectiveness evaluation represent the essential next phase of validation.<\/jats:p>","DOI":"10.1371\/journal.pone.0355752","type":"journal-article","created":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T17:48:43Z","timestamp":1788371323000},"page":"e0355752","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Designing a provider-led multimorbidity care model for fragmented insurance-based health systems: A mixed-methods study in Colombia"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1617-1667","authenticated-orcid":true,"given":"Omaira","family":"Valencia","sequence":"first","affiliation":[{"name":"Doctoral Program in Public Health, Universidad El Bosque","place":["Bogot\u00e1, Colombia"],"department":["Faculty of Medicine"]},{"name":"Fundaci\u00f3n Santa Fe de Bogot\u00e1","place":["Bogot\u00e1, Colombia"],"department":["Population Health Division"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2514-3318","authenticated-orcid":true,"given":"Oscar","family":"Bernal","sequence":"additional","affiliation":[{"name":"School of Government, Universidad de los Andes","place":["Bogot\u00e1, Colombia"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,9,2]]},"reference":[{"issue":"9836","key":"pone.0355752.ref001","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/S0140-6736(12)60240-2","article-title":"Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study","volume":"380","author":"K Barnett","year":"2012","journal-title":"Lancet"},{"key":"pone.0355752.ref002","unstructured":"Multimorbidity: a priority for global health research. London: Academy of Medical Sciences. 2018."},{"issue":"4","key":"pone.0355752.ref003","doi-asserted-by":"crossref","first-page":"430","DOI":"10.1016\/j.arr.2011.03.003","article-title":"Aging with multimorbidity: a systematic review of the literature","volume":"10","author":"A Marengoni","year":"2011","journal-title":"Ageing Res Rev"},{"key":"pone.0355752.ref004","doi-asserted-by":"crossref","first-page":"776","DOI":"10.1186\/s12889-015-2008-7","article-title":"Multimorbidity and the inequalities of global ageing","volume":"15","author":"S Afshar","year":"2015","journal-title":"BMC Public Health"},{"key":"pone.0355752.ref005","unstructured":"World Health Organization. Framework on integrated people-centred health services. Geneva: WHO. 2016."},{"issue":"1","key":"pone.0355752.ref006","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1016\/j.healthpol.2017.09.006","article-title":"Multimorbidity care model: recommendations from the consensus meeting of JA-CHRODIS","volume":"122","author":"K Palmer","year":"2018","journal-title":"Health Policy"},{"issue":"1","key":"pone.0355752.ref007","doi-asserted-by":"crossref","first-page":"895","DOI":"10.1186\/s12913-024-11351-y","article-title":"Care models for individuals with chronic multimorbidity: elements, impact, implementation challenges and facilitators for low- and middle-income countries","volume":"24","author":"A Endalamaw","year":"2024","journal-title":"BMC Health Serv Res"},{"key":"pone.0355752.ref008","article-title":"Situaci\u00f3n de la multimorbilidad en Colombia 2012\u20132016","author":"EA Alfonso-Sierra","year":"2018","journal-title":"Washington (DC): World Bank"},{"key":"pone.0355752.ref009","article-title":"Prueba piloto del modelo de gesti\u00f3n para multimorbilidad en Colombia","author":"EA Alfonso-Sierra","year":"2023","journal-title":"Washington (DC): World Bank"},{"key":"pone.0355752.ref010","volume-title":"Designing and conducting mixed methods research","author":"JW Creswell","year":"2018","edition":"3"},{"key":"pone.0355752.ref011","doi-asserted-by":"crossref","first-page":"2134","DOI":"10.1111\/1475-6773.12117","article-title":"Achieving integration in mixed methods designs-principles and practices","volume":"48","author":"MD Fetters","year":"2013","journal-title":"Health Serv Res"},{"issue":"7","key":"pone.0355752.ref012","doi-asserted-by":"crossref","first-page":"467","DOI":"10.7326\/M18-0850","article-title":"PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation","volume":"169","author":"AC Tricco","year":"2018","journal-title":"Ann Intern Med"},{"issue":"10","key":"pone.0355752.ref013","doi-asserted-by":"crossref","first-page":"2119","DOI":"10.11124\/JBIES-20-00167","article-title":"Updated methodological guidance for the conduct of scoping reviews","volume":"18","author":"MDJ Peters","year":"2020","journal-title":"JBI Evid Synth"},{"key":"pone.0355752.ref014","unstructured":"World Bank. Proposal for a comprehensive healthcare management model for multimorbidity in Colombia. Washington (DC): World Bank. 2023."},{"key":"pone.0355752.ref015","article-title":"Experiencias exitosas en la gesti\u00f3n de pacientes con multimorbilidad en Colombia","author":"World Bank","year":"2023","journal-title":"Washington (DC): World Bank"},{"key":"pone.0355752.ref016","doi-asserted-by":"crossref","DOI":"10.5334\/ijic.886","article-title":"Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care","volume":"13","author":"PP Valentijn","year":"2013","journal-title":"Int J Integr Care"},{"key":"pone.0355752.ref017","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1186\/1748-5908-4-50","article-title":"Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science","volume":"4","author":"LJ Damschroder","year":"2009","journal-title":"Implement Sci"},{"key":"pone.0355752.ref018","volume-title":"Group techniques for program planning","author":"AL Delbecq","year":"1975"},{"issue":"2","key":"pone.0355752.ref019","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1111\/j.1440-172X.2012.02017.x","article-title":"Nominal group technique: an effective method for obtaining group consensus","volume":"18","author":"N Harvey","year":"2012","journal-title":"Int J Nurs Pract"},{"issue":"4","key":"pone.0355752.ref020","first-page":"1","article-title":"Implementing the chronic care model for frail older adults in a community setting","volume":"19","author":"K Palmer","year":"2019","journal-title":"Int J Integr Care"},{"issue":"1","key":"pone.0355752.ref021","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1016\/j.healthpol.2017.08.008","article-title":"Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review","volume":"122","author":"V Struckmann","year":"2018","journal-title":"Health Policy"},{"issue":"5","key":"pone.0355752.ref022","doi-asserted-by":"crossref","first-page":"989","DOI":"10.1007\/s40520-022-02094-z","article-title":"Italian guidelines on management of persons with multimorbidity and polypharmacy","volume":"34","author":"G Onder","year":"2022","journal-title":"Aging Clin Exp Res"},{"key":"pone.0355752.ref023","unstructured":"Generalitat de Catalunya. Bases conceptuales y modelo de atenci\u00f3n a las personas con enfermedad cr\u00f3nica compleja (PCC) y avanzada (MACA). Barcelona; 2021."},{"issue":"1","key":"pone.0355752.ref024","first-page":"1","article-title":"How to strengthen financing mechanisms to promote value-based integrated care: a scoping review","volume":"123","author":"V Struckmann","year":"2019","journal-title":"Health Policy"},{"issue":"1","key":"pone.0355752.ref025","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0261953","article-title":"Impact of a high-risk multimorbidity integrated care model in Chile: a population-based study","volume":"17","author":"P Zamorano","year":"2022","journal-title":"PLoS ONE"},{"issue":"1","key":"pone.0355752.ref026","doi-asserted-by":"crossref","first-page":"1041","DOI":"10.1186\/s12913-023-09970-y","article-title":"Economic evaluation of a multimorbidity patient-centred care model in Chile","volume":"23","author":"P Zamorano","year":"2023","journal-title":"BMC Health Services Research"},{"key":"pone.0355752.ref027","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1016\/j.vhri.2023.07.003","article-title":"Evaluation of a transitional care strategy in adults with multimorbidity in Chile","volume":"38","author":"T Varela","year":"2023","journal-title":"Value Health Reg Issues"},{"key":"pone.0355752.ref028","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1186\/s12913-023-09412-9","article-title":"Evaluation of key performance indicators in a multimorbidity integrated care model in Chile","volume":"23","author":"T Varela","year":"2023","journal-title":"BMC Health Services Research"},{"key":"pone.0355752.ref029","doi-asserted-by":"crossref","first-page":"1516","DOI":"10.1186\/s13690-025-01516-4","article-title":"Implementation evaluation of a multimorbidity patient-centred care model in Chile","volume":"83","author":"JC Sapag","year":"2025","journal-title":"Arch Public Health"},{"issue":"11","key":"pone.0355752.ref030","doi-asserted-by":"crossref","first-page":"3830","DOI":"10.1111\/jan.15417","article-title":"Effectiveness of a case management model for people with multimorbidity in the Colombian health system","volume":"78","author":"L Mesa-Melgarejo","year":"2022","journal-title":"J Adv Nurs"},{"issue":"1","key":"pone.0355752.ref031","doi-asserted-by":"crossref","first-page":"965","DOI":"10.1186\/s12913-019-4785-7","article-title":"Process evaluation of implementation fidelity of the integrated chronic disease management model in two districts, South Africa","volume":"19","author":"L Lebina","year":"2019","journal-title":"BMC Health Serv Res"},{"issue":"3","key":"pone.0355752.ref032","article-title":"Chronic disease care integration into primary care services in sub-Saharan Africa: a \u201cbest fit\u201d framework synthesis and new conceptual model","volume":"10","author":"SR Harrison","year":"2022","journal-title":"Fam Med Community Health"},{"issue":"11","key":"pone.0355752.ref033","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2024-087451","article-title":"Barriers and facilitators for strengthening primary health systems for person-centred multimorbid care in low-income and middle-income countries: a scoping review","volume":"14","author":"D Zezai","year":"2024","journal-title":"BMJ Open"},{"issue":"1","key":"pone.0355752.ref034","doi-asserted-by":"crossref","first-page":"526","DOI":"10.1186\/s12913-025-12690-0","article-title":"Population risk stratification tools and interventions for chronic disease management in primary care: a systematic literature review","volume":"25","author":"D Golinelli","year":"2025","journal-title":"BMC Health Serv Res"},{"issue":"1","key":"pone.0355752.ref035","article-title":"Interventions for improving outcomes in patients with multimorbidity in primary care and community settings","volume":"1","author":"SM Smith","year":"2021","journal-title":"Cochrane Database Syst Rev"},{"issue":"1","key":"pone.0355752.ref036","doi-asserted-by":"crossref","DOI":"10.1111\/jebm.70015","article-title":"Medication Management in Patients With Polypharmacy in Primary Care: A Scoping Review of Clinical Practice Guidelines","volume":"18","author":"L Engels","year":"2025","journal-title":"J Evid Based Med"},{"key":"pone.0355752.ref037","article-title":"Innovative provider payment models for value-based integrated health systems","author":"L Lindner","year":"2023","journal-title":"Paris: OECD"},{"key":"pone.0355752.ref038","doi-asserted-by":"crossref","first-page":"104995","DOI":"10.1016\/j.healthpol.2024.104995","article-title":"Financial incentives for integrated care: A scoping review and lessons for evidence-based design","volume":"141","author":"D Yordanov","year":"2024","journal-title":"Health Policy"},{"key":"pone.0355752.ref039","first-page":"1604073","article-title":"Identification of population multimorbidity patterns in 3.9 million patients from Bogot\u00e1, Colombia","volume":"66","author":"C Saavedra-Moreno","year":"2021","journal-title":"Int J Public Health"},{"issue":"12","key":"pone.0355752.ref040","doi-asserted-by":"crossref","first-page":"1743","DOI":"10.1001\/jama.1988.03410120089033","article-title":"The quality of care. How can it be assessed?","volume":"260","author":"A Donabedian","year":"1988","journal-title":"JAMA"},{"key":"pone.0355752.ref041","doi-asserted-by":"crossref","first-page":"103496","DOI":"10.1016\/j.eclinm.2025.103496","article-title":"Effectiveness of organisation-directed interventions on healthcare professionals\u2019 adherence to clinical practice guidelines","volume":"88","author":"A Boskma","year":"2025","journal-title":"eClinicalMedicine"},{"key":"pone.0355752.ref042","doi-asserted-by":"crossref","DOI":"10.1016\/j.jval.2024.10.1766","article-title":"Multimorbidity healthcare delivery models: current situation in Colombia","volume":"27","author":"A Alvarado","year":"2024","journal-title":"Value Health"},{"key":"pone.0355752.ref043","doi-asserted-by":"crossref","DOI":"10.1016\/j.jval.2024.10.1460","article-title":"Challenges in implementing multimorbidity care models in Colombia\u2019s fragmented health system","volume":"27","author":"O Valencia","year":"2024","journal-title":"Value Health"},{"issue":"1","key":"pone.0355752.ref044","doi-asserted-by":"crossref","first-page":"913","DOI":"10.1186\/s12913-019-4737-2","article-title":"Evaluation of the primary care for chronic diseases in the high coverage context of the Family Health Strategy","volume":"19","author":"KCG Alves","year":"2019","journal-title":"BMC Health Serv Res"},{"issue":"1","key":"pone.0355752.ref045","doi-asserted-by":"crossref","first-page":"360","DOI":"10.1186\/s12875-024-02603-1","article-title":"Performance of health and wellness centre in providing primary care services in Chhattisgarh, India","volume":"25","author":"N Tripathi","year":"2024","journal-title":"BMC Prim Care"},{"issue":"1","key":"pone.0355752.ref046","doi-asserted-by":"crossref","first-page":"894","DOI":"10.1186\/s12913-023-09894-7","article-title":"Models of integrated care for multi-morbidity assessed in systematic reviews: a scoping review","volume":"23","author":"A Rohwer","year":"2023","journal-title":"BMC Health Serv Res"},{"key":"pone.0355752.ref047","volume-title":"How to implement integrated care? A framework with 12 overall strategies to transform care delivery","author":"V Struckmann","year":"2024"},{"issue":"1","key":"pone.0355752.ref048","doi-asserted-by":"crossref","first-page":"10","DOI":"10.5334\/ijic.5937","article-title":"The Impact of Payment Reforms on the Quality and Utilisation of Healthcare for Patients With Multimorbidity: A Systematic Review","volume":"22","author":"TEP Remers","year":"2022","journal-title":"Int J Integr Care"},{"key":"pone.0355752.ref049","article-title":"Resoluci\u00f3n 229 de 2020","author":"Ministerio de Salud y Protecci\u00f3n Social","year":"2020","journal-title":"Bogot\u00e1: MinSalud"},{"key":"pone.0355752.ref050","article-title":"Plan decenal de salud p\u00fablica 2022\u20132031","author":"Ministerio de Salud y Protecci\u00f3n Social","year":"2022","journal-title":"Bogot\u00e1: MinSalud"},{"issue":"8","key":"pone.0355752.ref051","doi-asserted-by":"crossref","first-page":"929","DOI":"10.1016\/j.jval.2016.02.017","article-title":"Country-level cost-effectiveness thresholds: initial estimates and the need for further research","volume":"19","author":"B Woods","year":"2016","journal-title":"Value Health"},{"issue":"1","key":"pone.0355752.ref052","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1186\/s12916-024-03263-9","article-title":"Co-designing care for multimorbidity: a systematic review","volume":"22","author":"J Sumner","year":"2024","journal-title":"BMC Med"},{"key":"pone.0355752.ref053","article-title":"Health at a Glance 2023: OECD Indicators","author":"OECD","year":"2023","journal-title":"Paris: OECD Publishing"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0355752","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T17:48:56Z","timestamp":1788371336000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0355752"}},"subtitle":[],"editor":[{"given":"Surangi","family":"Jayakody","sequence":"first","affiliation":[{"name":"University of Warwick","place":["UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND"]}],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,9,2]]},"references-count":53,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9,2]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0355752","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,2]]}}}