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Poster Abstracts

Integrated care for patients with multimorbidity: co-production of the Primary Organization- and Relations Team


Kirstine Benthien ,

Center For Clinical Research And Prevention, Frederiksberg University Hospital, Denmark, DK
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Michaela Schiøtz,

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Louise Jacobsen

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Introduction: The number of involved healthcare providers and treatment trajectories increases with multimorbidity and may involve adverse outcomes such as redundant work and testing, over-utilization of medicine, medical and communication errors, and adverse hospitalizations. Furthermore, lacking continuity is detrimental to achieving personalized healthcare. Justifiably, patients and caregivers express a prominent need for coordinated and patient-centered healthcare.

Aims and methods: The aim of this study was to develop a model for integrated care for patients with multimorbidity: The Primary Organization and Relations- Team (PORT). The clinical aim of PORT is to reduce the treatment burden and improve quality of life for patients with multimorbidity and complex needs, and their caregivers. The development of PORT is ongoing and formed by a co-production approach including evidence review and stakeholder consultation through group and individual interviews analyzed with systematic text condensation presented in the following.

Results: The following stakeholders have contributed: Patients and caregivers, general practitioners, healthcare professionals and leaders from three hospital departments, and healthcare professionals and leaders from two municipalities – a total of 29 persons. Four themes emerged from the analyses: Healthcare fragmentation: patients’ numerous simultaneous healthcare trajectories were complex for all involved, dynamic information sharing: communication was one-way with standardized products and called for intersectoral insight into patient records, intersectoral healthcare decisions: roles and responsibilities were unclear and treatment decisions confined to each sector, and patient involvement: healthcare needs varied across patients and time and the healthcare system too inflexible to meet individual needs. In consequence, the PORT model should include care coordination, insight into patient records across sectors, a frame for making intersectoral healthcare decisions, and patient-centered healthcare planning.

Conclusions: The present healthcare system divided into three sectors sets up barriers for integrated care and the PORT model should compensate by focusing on information sharing, intersectoral healthcare decisions, and involving and supporting patients in healthcare planning.

Implications: The PORT steering committee will decide on the exact form and implementation of PORT to be tested in the upcoming pilot study.

How to Cite: Benthien K, Schiøtz M, Jacobsen L. Integrated care for patients with multimorbidity: co-production of the Primary Organization- and Relations Team. International Journal of Integrated Care. 2022;22(S3):247. DOI:
Published on 04 Nov 2022.


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