Clinic for Multimorbidity: An Innovative Approach to Integrate General Practice and Specialized Health Care Services

Development

The CM was developed in 2012, co-created by clinicians, management, and facilitating officers from Silkeborg Regional Hospital, together with local GPs. The CM builds on elements of the Chronic Care Model and was founded as user-driven innovation; clinical experience, along with an expressed need from the healthcare professionals collaborating across the primary and secondary sector, and research underpinning the need for integration of existing services. The assumptions behind setting up this organization were, that a joint treatment plan achieved from intersectoral and interdisciplinary collaboration with a person-centered approach would optimize the quality of care and support GPs in care management of complex patients with multimorbidity.

The Clinic for Multimorbidity

People with complex health problems and suffering from at least two chronic conditions (including psychiatric illnesses) can be referred to the CM by their GP. When a referral is accepted, a personal consultant initially collects all relevant information from the patient files and writes a chronological summary of the patient’s medical history and previous treatments. The consultant requests relevant tests needed prior to the visit at the clinic, and a pathway coordinator (nurse or secretary) organizes these tests to all be conducted in one day closely before the primary consultation. The personal consultant is a medical doctor and acts as a generalist across the spectrum of medical conditions.

At the primary consultation to the CM, the coordinator welcomes the patient and measures vital values. The medication is reviewed with the patient by a pharmacist, followed by an assessment from a physiotherapist and an occupational therapist. The pharmacist and therapists report any anomalies/focus areas to the personal consultant before the consultation with the patient takes place. The personal consultant then has a consultation with the patient, focusing on the patient’s individual needs and concerns. After this, and on the same day, a multidisciplinary conference takes place, with the participation of the personal consultant, other relevant medical specialists from the Diagnostic Centre, the pharmacist, therapists, and the pathway coordinator, at which a joint and comprehensive treatment plan for the patient is proposed. Conference participants are selected by the personal consultant and organized by the pathway coordinators. It is possible for the GP to participate by videoconference. The patient, who does not attend the conference, is offered a meal and a place to rest, while awaiting the outcome of the conference. At the conference, a short summary of the patient’s medical history, medication, and current issues are presented. Treatment options are discussed and when agreed upon by all participants, a proposal for a final treatment plan is made. This can include alterations in current medication, suggestions on discontinuation or tapering, establishing necessary homecare and a rehabilitation plan. After the conference, the personal consultant presents the patient with a proposed treatment plan. The treatment plan is agreed upon, then sent to the GP and stored in the hospital’s electronic records. This can end the intervention or when relevant, there may be follow-up visits. Care following the CM is placed back with the GP, who is now provided with specialist suggestions in a unified treatment plan.

Thus, the CM integrates primary care with specialized care and offers a holistic overview of patients with complex multimorbidity and their problems to support GPs responsible for the care and focusses specifically on the patient’s individual needs.

Data description

We included descriptive data on the 141 patients aged ≥18 years, referred to the CM at Diagnostic Centre, Silkeborg Regional Hospital between May 2012 and November 2017.

The personal consultant or pathway coordinator had documented; patients seen in the CM, age and gender, Body Mass Index, diagnoses presented using International Classification of Diseases, 10^th revision, referring units (GP or hospital), clinical examinations and tests, whether video conference was involved (yes/no), medical specialties involved, medication usage based on the Anatomical Therapeutic Classification System, tobacco usage (smoker, on occasions, former and never), and alcohol consumption (0–1, 2–10 and >10).

Information on patients with follow-up visits three months after visiting the CM were retrieved from the patient administrative system, which keeps record of all hospitalizations and outpatient treatments in Central Region Denmark.

Questionnaires, which included data on working status, educational level, civil status, and physical and mental wellbeing, were filled out by the patients at the CM. Working status was grouped as working (full/part-time and sick leave), not working, on pension (including early retirement), undergoing education, or on social benefit. Educational level was grouped into <10, 10–15, and >15 years of education according to the International Standard Classification of Education, 11^th revision. Civil status was reported dichotomized as living with partner/living alone. To assess well-being, the 12-item Short Form Health Survey (SF-12) instrument was used [33]. The SF-12 is comprised of eight subscales. These were summarized into a physical component score (PCS) and a mental component score (MCS), in accordance with the guidelines for the SF-12 instrument. Both scores range between 0 and 100, with a higher score indicating better health.

Statistical analysis

Descriptive statistics by counts with percentages and medians with interquartile intervals were used. All analyses were conducted in Stata version 17.

In summary

The CM involves health care collaboration, knowledge sharing and shared treatment planning. It was the first of its kind in Denmark and creates an innovative patient pathway for people with multiple diseases. It integrates different care professionals and links primary and hospital sectors. The 141 patients visiting the CM during the investigation period were characterized by having a high number of chronic conditions, a high medicine usage, and a low self-reported physical well-being. Overall, they represented a very complex group of patients with multimorbidity, requiring a wide range of examinations and involvement of several specialists.

Comparison with existing literature

Research on interventions aiming to support the GPs in care management of patients with multimorbidity are sparce [23242534]. In an umbrella review by Damery et al., one of the main findings on integrated care effective interventions to reduce hospital activity concerned multidisciplinary teams [35]. Another umbrella review by Flanagan et al. presented promising evidence of effectiveness in case management interventions to improve the patient’s quality of life [36]. Furthermore, across several European countries there is consensus that key aspects for integrated care involve a holistic view of the patient, continuity of care in the form of single contact points and continuous communication, alignment of services, good relationships, trust, and patient involvement [37]. The CM attempts to incorporate or facilitate these aspects while the role as gatekeeper and case manager remains with the GP. Since the establishment of the CM in 2012 more outpatient clinics and care pathways with provision of integrated care solutions for patients with multimorbidity have emerged in hospitals in Denmark, which to some extent, resemble the CM [2538]. Setting up an organization with multidisciplinary efforts require much coordination [38] and the inclusion of patients in the CM is reliant on GP awareness for an add-on and collaborative effort of specialties. Caring for and coordinating care for patients with complex multimorbidity is a demanding task [123940]. One study found that the GP’s time consumption and the burden of contacts tend to rise with the number of chronic conditions [8], another study found that service provision for chronic care vary considerably across general practices [41]. The CM had a low inclusion as only 141 patients underwent the intervention during the time of investigation. We question whether the intervention was sufficiently implemented, as GP awareness (and finding the offer beneficial) is the cornerstone for referral to the CM. A qualitative study by Nissen et al. found that GPs, who referred to the CM, experienced difficulties in determining the suitable time for referral, and consequently referred few and not necessarily the most in need [13].

Our results show that patients seen at the CM had a high number of diagnoses and a high level of polypharmacy, requiring involvement of several healthcare professionals. Compared to a Danish national health survey with four or more chronic conditions [42], CM patients experienced lower physical well-being (score 26 versus 38), underpinning that these were physical fragile patients. Providing the GPs with a referral option for complex patients with multimorbidity was the intention with the CM, and risk stratification may be effective in locating patients with complexities suited for referral. Other common characteristics seen in the CM were female gender, high age, no labor market attachment, and a high number of patients with conditions or drugs related to the circulatory system. These resemble characteristics in former intervention studies aimed at people with multimorbidity [384344].

When dealing with patients with multimorbidity, GP care is commonly influenced by insufficient communication and coordination, unclear divisions of roles, and responsibilities across sectors [13]. Care transition from the GP to the CM and vice versa may also be prone to these challenges. Nissen et al. also found that the CM needs clarity on intervention elements in terms of “who does what”, for its users to find it lucrative. Care suggestions from the CM are provided to the GP, who are left with realizing these suggestions, which may include difficultly obtainable goals [13]. Follow-up visits as part of a personal health care plan took place but was not standard. These elements may affect GP referral and in part explain the low inclusion of patients in the CM.

Implications

The CM was an attempt to create a more efficient trajectory for patients with complex multimorbidity and in need of case management. The CM was an intervention grounded in the Chronic Care Model and the pyramid of risk stratification [20], where the most challenged patients and their GPs are provided with a supportive solution. More information on social determinants of health would expand our description and had social determinants been incorporated in the care model, it might have facilitated a broader approach to care [45]. Still, the CM comprises many of the elements from the Chronic Care Model for fostering productive chronic care delivery: integrating specialists for decision support and case management for complex patient care, sharing information and responsibilities, making action plans and goal setting, and promoting safe high-quality care across specialties and sectorial borders. The focus was to support GPs in being lead on the disease course and to support the decision-making on treatment by offering a review of the patients’ complete disease status including advice on optimizing the treatment plan, without having to send the patient for serial examinations by different medical specialists. Although, the GP serves as gatekeeper to specialized care in this context, the CM may still be relevant to systems without this initial point of contact. In this case, it would be relevant to consider how the patient is referred and how responsibility is placed following the intervention. The CM has the advantage of being a clinic with possibility to coordinate collaboration and knowledge-sharing of specialists for already diagnosed patients and ought not to be considered as a diagnostic clinic.

Strengths and limitations

The data is collected prospectively over a long period and provides a detailed description of the practice implemented. As a descriptive case study, it lacks results on effectiveness and costs. Which decisions were made at the conference and how often changes were made in the medical care plan lacks description. The CM was not established as a research intervention, instead the intervention was formed from an identified need through clinical experience and former literature and theory, and an inclination to create an integrated solution. In its simplicity, we present a case description and believe that elements of the CM can be an inspiration to future care organization for patients with multimorbidity. Practicalities of organizing the clinic are manageable, however, this demands close collaboration between diverse healthcare professionals and a general prioritizing of a resource-consuming intervention. Research is needed on assessing costs and effectiveness of the CM. Research is also needed on the care outcome of the CM intervention and how this affects patient care following the intervention.