出版社：Utrecht University, Maastricht University, Groningen University
摘要：Background : In the Capital Region of Denmark, about 60% of the population over 65 years has multimorbidity, i.e. two or more concurrent chronic diseases. General practice plays a central role in ensuring that citizens with multimorbidiy receive continuous care, as well as the best possible treatment. The overall objective of this project is therefore to develop an organizational model for the management of multimorbidity in general practice. Material or methods : The project is a pilot project lasting two years. An organizational model for multimorbidity in general practice has been developed based on literature findings and empirical experience. The model is being tested among 60 patients with multimorbidity followed at the large general practice clinic in Copenhagen with six general practitioners, several nurses and secretaries. The practice has about 8.000 patients enrolled. The effects of the model are evaluated using before and after measurements for patient reported outcomes and relevant clinical data. The process is evaluated in qualitative studies with the physicians, clinic’s personnel and the patients involved. Results : The organizational model covering new forms of work and collaboration in primary care, with the general practice at the centrum, is developed to support high quality care managing the population with multimorbidity. The model includes: 1 preparation and validation of an algorithm to assist general practicitioners in monitoring their population with multimorbidity; 2 preparation of individual and personal patient management plans; 3 extension of consultation time in general practice for patients with multimorbidity; 4 development of effective communication forms for closer collaboration between general practice, municipalities and outpatient clinics in hospitals; 5 establishment of a care manager function in general practice for patients with multimorbidity. Conclusion : The proposed model is expected to support general practice optimizing treatment and care in patients with multimorbidity. Furthermore, the model ensures that patients' needs are central in the overall multimorbidity management course.
