Abstract
Introduction: Virtual four-part Meetings, V4M is a Danish Research Project in the Region of Zealand. This action-research-based project intervenes in the patient care pathways of frail elderlies and multimorbid patients in the intersection of municipality care and hospitalization. The purpose of the project is to i) Create a mutual understanding between primary care and secondary care actors, ii) include the patient’s wishes and relatives in shared decision-making, and iii) Develop a cross-sectorial infrastructure of communication that supports dialogue between the central stakeholders of multimorbid patients’ care pathways.
Background: Elderly patients with multimorbidities are prone to (re)admissions to hospital. They are highly dependent on intersectional collaboration between municipality care, home, GP, and specialist hospital treatment – “the 4” parties necessary for continuity and quality of treatment and care. These four parties are located in geographically and organizationally dispersed settings, which challenges their exchange of information and communication and is thus a barrier to their collaboration and development of shared plans of action. Further innovative cross-sectoral and interdisciplinary collaborations are urgently called for, as the demographics of the region indicate a substantial future increase of elder citizens with many care needs. The vision is to create a stable environment for multimorbid patients with circular care pathways through holistic, interdisciplinary, video-mediated collaborations that include the patients and relatives’ wishes.
Method: Designing of interorganizational video guidelines: The project tests virtual meetings between the four parties at two passage points of the patient care pathways: i) when frail elderly persons are admitted to hospital to ensure a shared understanding of the patients’ needs, and ii) when patients are discharged to municipality care to safeguard the transition and continuity of care. A communication guide for video meetings between the four parties is developed by the action research group. The group is interdisciplinary with participants from each of the organizational settings, i.e., the home, representing the patient’s and relatives’ perspectives, the GP, representing the perspective of the GP’s clinic, the municipality, including the perspectives of care and rehabilitation, and the hospital, especially nurses and doctors with specialties in cardiology and geriatrics. Twenty V4Ms are conducted, with follow-up qualitative interviews of patients/relatives and health professionals, evaluation workshops, time-registration forms and questionnaires, and subsequently content and in-depth data analysis.
Results: The preliminary findings from Virtual-4-meetings with hospitalized elderly persons point to the following outcomes:
•the negotiation of differences in their horizons of understanding
•new levels of collectively learning
•shared decision making that empowers each part on their prospective tasks and responsibilities
•adjusted and coordinated actions
•the patient’s experience of an improved care path-circuit between the sectors.
•more efficient citizen-centered solutions.
Conclusion: The findings show that, given a stable technical infrastructure and organizational resources to plan and participate in V4M it is possible to align the patient’s wishes and care plans in joint action. Virtual meetings thus transcend the organizational boundaries of hospital, municipality, GP, and the home, and create a new, cross-sectional context of learning and understanding that potentially benefits the quality of care.