Abstract
Background: Multimorbidity poses a significant challenge for healthcare systems. There is an urgent need for targeted interventions for individuals with high complexity to better coordinate care across hospital specialists and to support general practice. However, there is limited evidence on how best to organise this care. We propose a differentiated care approach through our Clinic for Multimorbidity to provide specialised care at the required level.
Approach: We have redesigned our existing 'Clinic for Multimorbidity', which has existed since 2012. The clinic aims to integrate care from various healthcare professionals and medical specialties, promoting shared and coordinated care for adults with complex multimorbidity. The patients are referred from general practice. Healthcare professionals and researchers involved in the clinic, re-designed the clinic with differentiated care options according to the required level of support:
I.A telephone line for general practitioners with specialist advice about the management of multimorbidity and/or polypharmacy.
II.A medication review with the patient present, conducted by a specialist in clinical pharmacology. Medication changes are agreed upon with the patient and followed up with control consultations.
III.A patient consultation with a physician, including review of previous medical records and current medications, as well as assessments from occupational and physical therapists. After the patient consultation, a multidisciplinary team meeting is held with selected medical specialists, to develop a treatment plan. The patient's general practitioner can participate via video. In agreement with the patient, a nurse coordinator facilitates follow-up based on the recommendations.
Using a stepped-wedge randomized controlled design, general practices are enrolled based on their geographical locations as hospital clusters. The project includes two studies within the fields of clinical and health services research: an implementation study to assess the feasibility of the differentiated pathways and an effect study.
Results: The data collection began in September 2024. The implementation study results will be based on Proctor et al.'s implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, and penetration. Data will be gathered through interviews with patients and general practitioners, as well as measurements related to referral practices, costs, and feasibility.
Effectiveness outcomes will involve perceived health-related quality of life, treatment burden, depression, and anxiety. Additionally, inappropriate medication, symptoms, mortality, care continuity, healthcare utilization, and the initiation of health-promoting initiatives.
Implications: Complex multimorbidity and polypharmacy necessitate multidisciplinary approaches and stepped care to fit the appropriate level of care. We propose a differentiated model aimed at improving patient well-being and care, reduce inappropriate medication use, and support general practitioners and hospitals in their management of these patients, allowing for more efficient resource allocation. From phone consultations to multidisciplinary assessments, other healthcare settings can adjust the level of care according to their capacities and patient needs, making this a scalable model.