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Poster Abstracts

Integrating medical specialties and outpatient appointments - A novel pathway for multimorbid patients encountering several outpatient clinics


Catherine Bell

Diagnostic Centre, University Reseach Clinic For Innovative Patient Pathways, DK
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Multimorbidity has attracted growing interest over the recent years because it poses a major challenge to health care. It is prevalent in at least every fourth adult person and the rate is rapidly rising with increasing age. The everyday-life of multimorbid patients is often influenced by difficulties in managing their conditions, complex drug regimes and attending multiple appointments in a fragmented health system. A huge amount of hospital activities takes place in outpatient clinics. Thus, optimal care for multimorbid patients necessitates a need for more coordination and interdisciplinary collaboration.

Practice change implemented

We developed a patient pathway for multimorbid patients seen in two or more outpatient clinics. Coordinators, assigned to improve the care flow, review and align the patient’s appointments and tests in agreement with the patient’s wishes. Outpatient consultations are arranged to take place the same day and schedules for care providers are coordinated. The patients’ attendance in outpatient clinics are planned  sequentially where the delivering specialty writes a summary to the subsequent specialty. Afterwards, the involved physicians and nurses attend an interdisciplinary conference, resulting in a joint treatment plan, with feedback and notice of modifications, which is delivered to the patient and general practice.


To reduce the number of appointments to outpatient clinics, to integrate and coordinate tests, consultations and care, and to support medical specialties and GPs in coordinating care.

Population and stakeholders

Multimorbid patients seen in two or more outpatient clinics constitute the target population. Stakeholders include all healthcare professionals involved in the patients’ health care.


The multidisciplinary outpatient pathway and data collection was implemented August 2018.



This multidisciplinary patient pathway involves aligning and coordinating tests, outpatient appointments, healthcare collaboration, mutual knowledge sharing and using a shared treatment plan facilitating integrated care. Until now, we have identified 1683 patients with long-term trajectories in two or more outpatient clinics, leaving 1115 eligible patients within the five medical specialties under study. Data collection is on-going, and 134 patients (median age 72 years, 38% females) have been enrolled. We present results on feasibility by tracking the flow of the patient pathway and acceptability by conducting surveys among patients and healthcare professionals.


The multidisciplinary pathway delivers a comprehensive attempt to align and reduce hospital appointments, coordinates different care, giving an unambiguous health strategy.


Practicalities of organising this pathway are manageable and can be transferred to other hospital settings. This demands close collaboration between diverse healthcare professionals and a general prioritising of collaboration between medical specialties.


This novel approach to coordinate and integrate complex, multimorbid patients’ pathways involves relevant specialities, instead of mono-targeting diseases. It reduces the number of appointments, promotes collaboration between specialties and supports patient and GP focus. It seems feasible to establish an interdisciplinary organisation targeting multimorbidity.

Discussions and lessons learned

Multidisciplinary approaches are supposed to ease the handling of multimorbid trajectories in order to support patients with severe disease complexity. Integrating medical specialities and healthcare initiatives requires prioritising in a complex re-organisation of existing approaches.


How to Cite: Bell C. Integrating medical specialties and outpatient appointments - A novel pathway for multimorbid patients encountering several outpatient clinics. International Journal of Integrated Care. 2021;21(S1):314. DOI:
Published on 01 Sep 2021.


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