Towards coordination and tailoring of hospital care for patients with multimorbidity

Patients with multimorbidity (two or more chronic conditions) often receive fragmented hospital care, organized around separate medical specialties and focused on single diseases. Without coordination and tailoring of care, fragmented hospital care can lead to adverse outcomes. In this thesis, Verhoeff explored which strategies can contribute to improved coordination and tailoring of hospital care when multiple medical specialties are involved, in order to ensure good quality and experience of hospital care for patients with multimorbidity. First, Verhoeff explored the current Dutch hospital care for multimorbidity. These studies showed that maintaining an overview can be complex and that care professionals experience barriers for tailoring and coordinating care. Next, she developed and tried out an intervention for hospital care coordination. She learned that it is important to show the results of coordination and tailoring, and that patient selection should be refined. Her other studies illustrated how hospitals could use their own electronic health record (EHR) data to find patients who benefit most from coordination and tailoring of care.A shared vision and efforts throughout the entire healthcare system are necessary to improve coordination and tailoring of hospital care. Verhoeff recommends introducing a multimorbidity care perspective in hospitals, and organization and innovation of collaboration between care professionals in case of multimorbidity. It is important to acknowledge that coordination and tailoring of care are extra tasks that need prioritization, organization, and financing. In the future, hospitals offer tailored and coordinated hospital care for patients with multimorbidity, that benefits both patients and healthcare professionals

Development and internal validation of prediction models for future hospital care utilization by patients with multimorbidity using electronic health record data

OBJECTIVE: To develop and internally validate prediction models for future hospital care utilization in patients with multiple chronic conditions. DESIGN: Retrospective cohort study. SETTING: A teaching hospital in the Netherlands (542 beds) PARTICIPANTS: All adult patients (n = 18.180) who received care at the outpatient clinic in 2017 for two chronic diagnoses or more (including oncological diagnoses) and who returned for hospital care or outpatient clinical care in 2018. Development and validation using a stratified random split-sample (n = 12.120 for development, n = 6.060 for internal validation). OUTCOMES: ≥2 emergency department visits in 2018, ≥1 hospitalization in 2018 and ≥12 outpatient visits in 2018. STATISTICAL ANALYSIS: Multivariable logistic regression with forward selection. RESULTS: Evaluation of the models’ performance showed c-statistics of 0.70 (95% CI 0.69–0.72) for the hospitalization model, 0.72 (95% CI 0.70–0.74) for the ED visits model and 0.76 (95% 0.74–0.77) for the outpatient visits model. With regard to calibration, there was agreement between lower predicted and observed probability for all models, but the models overestimated the probability for patients with higher predicted probabilities. CONCLUSIONS: These models showed promising results for further development of prediction models for future healthcare utilization using data from local electronic health records. This could be the first step in developing automated alert systems in electronic health records for identifying patients with multimorbidity with higher risk for high healthcare utilization, who might benefit from a more integrated care approach

A hospital care coordination team intervention for patients with multimorbidity:A practice-based, participatory pilot study

Objectives: This study aims to develop and pilot a hospital care coordination team intervention for patients with multimorbidity and identify key uncertainties Methods: Practice-based, participatory pilot study with mixed methods in a middle-large teaching hospital. We included adult patients who had visited seven or more outpatient specialist clinics in 2018. The intervention consisted of an intake, a comprehensive review by a dedicated care coordination team, a consultation to discuss results and two follow-up appointments. We collected both quantitative and qualitative data. Results: Out of 131 invited patients, 28 participants received the intake and comprehensive review. The intervention resulted in mixed outputs and short-term outcomes. Among the 28 participants, 21 received recommendations for at least two out of three categories (medication, involved medical specialists, other). Patients’ experienced effects ranged from no to very large effects. Key uncertainties were how to identify patients with a need for care coordination and the minimum of required data that can be collected during regular clinical care with feasible effort. Discussion: Recruitment and selection for hospital care coordination should be refined to include patients with multimorbidity who might benefit most. Outcomes of research and clinical care should align and first focus on evaluating the results of care coordination before evaluating health-related outcomes.</p

A hospital care coordination team intervention for patients with multimorbidity:A practice-based, participatory pilot study

Objectives: This study aims to develop and pilot a hospital care coordination team intervention for patients with multimorbidity and identify key uncertainties Methods: Practice-based, participatory pilot study with mixed methods in a middle-large teaching hospital. We included adult patients who had visited seven or more outpatient specialist clinics in 2018. The intervention consisted of an intake, a comprehensive review by a dedicated care coordination team, a consultation to discuss results and two follow-up appointments. We collected both quantitative and qualitative data. Results: Out of 131 invited patients, 28 participants received the intake and comprehensive review. The intervention resulted in mixed outputs and short-term outcomes. Among the 28 participants, 21 received recommendations for at least two out of three categories (medication, involved medical specialists, other). Patients’ experienced effects ranged from no to very large effects. Key uncertainties were how to identify patients with a need for care coordination and the minimum of required data that can be collected during regular clinical care with feasible effort. Discussion: Recruitment and selection for hospital care coordination should be refined to include patients with multimorbidity who might benefit most. Outcomes of research and clinical care should align and first focus on evaluating the results of care coordination before evaluating health-related outcomes.</p

Coordinating and tailoring hospital care for patients with multimorbidity:who will take the lead?

OBJECTIVE: To gain insight in medical specialists' and nurse practitioners' opinions on multimorbidity and coordination and tailoring of hospital care.DESIGN: Exploratory mixed-method design.METHOD: From August 2018 until January 2019, 35 Dutch medical associations were asked to forward a digital survey with open- and close-ended questions to their members. We used qualitative and quantitative methods to analyze the data. The main themes were identified with inductive, thematic analysis.RESULTS: There were 554 respondents from 22 associations, 43% of the medical specialist respondents were internist (n=221). The qualitative analysis of the answers regarding what is required in hospital care for patients with multimorbidity resulted in eight themes at the patient's, professional's and hospital organization's level. To the open question about who should take the lead, respondents most often answered the geriatrician or internist, followed by the general practitioner, 'the care professional who is treating the main problem', a nurse practitioner/physician assistant and the 'attending physician of the primary team'. All geriatricians and almost all internists felt they possessed the competencies to take the lead in hospital care for patients with multimorbidity.CONCLUSION: Medical specialists' and nurse practitioners' diverse ideas about who should take the lead in hospital care for patients with multimorbidity were a noteworthy finding. It is important to start local conversations about how to divide roles and responsibilities regarding the coordination and tailoring of hospital care for patients with multimorbidity.</p