A Multidisciplinary Outpatient Pathway

Patients with complex chronic multiple illnesses constitute an increasing challenge and more evidence-based knowledge of effective practice is required. In Denmark and the rest of the world, improved health care, public health, and increased focus on early diagnosis have led to increases in life expectancy resulting in a growing population of older people living with multiple long-term conditions (multimorbidity). Today, every fourth Dane suffers from more than one concomitant chronic or severe disease, estimated to rise to 60% for those over 65 years. National and international health care is organised and targeted as specialised, mono-diagnostic efforts for single diseases leading to lack of coordination and failure to integrate multidisciplinary patient trajectories. Danish research shows that general practice is challenged by insufficient collaboration between professionals involved in the treatment. Despite this, there exists limited evidence of initiatives aiming to improve care for multimorbid patients. This study aims to: 1. identify chronic multimorbid patients and to analyse their use of two or more outpatient clinics, their general use of health care utilisations and their disease pattern and characteristics (Cross-sectional study using national registers). 2. develop an innovative organisational structure around a multidisciplinary outpatient pathway for multimorbid patients and to pilot-test it (feasibility study) 3. phase-III test a multidisciplinary outpatient pathway and to preliminarily evaluate the effects in patients and health professionals and on resource utilisations (effect study)