Bell Cathrine, Vedsted Peter, Kraus Dorte Gunver Adsersen, Fredberg Ulrich, Jeffery Linda, Dahlgaard Marianne Bjørn, Aarhus Rikke, Appel Charlotte Weiling
Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark.
Research Unit for General Practice, Faculty of Health, Aarhus University, Denmark.
Int J Integr Care. 2023 Jun 12;23(2):25. doi: 10.5334/ijic.7015. eCollection 2023 Apr-Jun.
Caring for patients with multimorbidity in general practice is increasing in amount and complexity. To integrate care for patients with multimorbidity and to support general practitioners (GPs), the Clinic for Multimorbidity (CM) was established in 2012 at Silkeborg Regional Hospital, Denmark. This case study aims to describe the CM and the patients seen in it.
CM is an outpatient clinic that offers a comprehensive one-day assessment of the patient's complete health status and medication. GPs can refer patients with complex multimorbidity (≥2 chronic conditions). It involves collaboration across medical specialties and healthcare professions. The assessment is completed with a multidisciplinary conference and recommendation.In all, 141 patients were referred to the CM between May 2012 and November 2017. The median age was 70 years, 80% had more than five diagnoses, and in median patients had a usage of 11 drugs (IQI, 7-15). Physical and mental health was reported low (SF-12 score: 26 and 42). In median four specialties were involved and 4 examinations (IQI, 3-5) conducted.
The CM offers innovative care by bridging and exceeding conventional boundaries of disciplines, professions, organizations, and primary and specialized care. The patients represented a very complex group, requiring many examinations and involvement of several specialists.
在普通医疗实践中，照顾患有多种疾病的患者的工作量和复杂性都在增加。为了整合对患有多种疾病患者的护理并支持全科医生（GP），丹麦锡尔克堡地区医院于2012年设立了多病症诊所（CM）。本案例研究旨在描述CM及其所接待的患者。
CM是一家门诊诊所，提供对患者完整健康状况和用药情况的全面一日评估。全科医生可以转诊患有复杂多种疾病（≥2种慢性病）的患者。它涉及跨医学专科和医疗保健专业的协作。评估通过多学科会议和建议完成。2012年5月至2017年11月期间，共有141名患者被转诊至CM。中位年龄为70岁，80%的患者有超过五种诊断，中位患者使用11种药物（四分位间距，7 - 15）。据报告，患者的身心健康状况较差（SF - 12评分：26和42）。中位涉及四个专科，进行了4项检查（四分位间距，3 - 5）。
CM通过跨越并超越学科、专业、组织以及初级和专科护理的传统界限，提供创新护理。这些患者代表了一个非常复杂的群体，需要进行许多检查并涉及多位专家。
