出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : The prevalence of multimorbidity is high in Denmark. Care provision in multimorbid patients is often characterized to be fragmented, the quality level is not satisfactory, and patients suffer from both disease and treatment burden. We previously reported a patient centered organizational model aiming to improve quality and coordination of care for complex multimorbid patients followed in general practice in Denmark. The basic elements of the model are: extension of consultation time in general practice; establishment of a care manager function; improved inter-sectorial communication of care plans; increased rates of referrals to rehabilitation and medication review; transfer of ambulatory controls to general practice. The objective of this study is to assess feasibility of the organizational model for further evaluation in a RCT. Methods : The model was implemented in a large general practice clinic in Copenhagen. The patients were selected from a patient list generated by the practice’s IT provider. Data on chronic conditions, demographics, and medical measures was collected. Patients answered PACIC and EDQ5 questionnaires. Further, focus group interviews were performed with patients and professionals to obtain information on important subjects such as patient centeredness, level of integration of care, information flow, and medication satisfactory and safety. Results : Forty-six patients with at least two of the three selected chronic conditions (diabetes, heart and lung disease) were included in the study. The mean (SD) age of the included patients was 72 years (9,3); 48% were men. The PACIC questionnaire showed fair perceived quality of care, the EDQ5 questionnaire showed very low health related quality of life. Focus group interviews with the patients revealed that they were satisfied with longer consultation time; perception of the care coordination initiatives depended on the practice personnel involved. Focus group interviews with the professionals pointed towards communication barriers between general practice and ambulatories; emphasized the importance of patient centered approach to realize patients’ daily life problems; and elucidated ambiguity of longer consultation time as both necessary for good care quality and often practically impossible on a daily basis. Discussion : Studies show that organizational innovations in general practice, such as extended consultation time or patient care reviews, can improve continuity of care for patients with multimorbidity. Conclusions : The developed patient centered organizational model for multimorbidity based in general practice in Denmark should undergo a focused revision for a RCT assessment. Lessons learned : The development of feasible organizational innovations in existing health- and social care systems is a task that requires collaborative actions and several iterations. Limitations : The developed model was tested in one large general practice clinic where several GPs, nurses and other practice personnel collaborate. As general practices in Denmark are heterogeneous, precautions should be taken with respect to generalization of the conclusions. Suggestions for future research : Model refinements and improvements important in the second iteration have been proposed: improve time allocation between GPs and practice personnel; share patients electronic medical records between professionals the different health organizations and social care sector; develop collaboration between the different organizations; and implement of strong leadership.
关键词：multimorbidity ; model of care ; general practice ; focus groups ; denmark
