Closing the Gap: Multidisciplinary Coordination of a Care Plan for Patients with Multimorbidity
Authors: Gans Emma Adriana , De Ruijter Ursula , Van der Heide Agnes , Van Munster Barbara , De Groot Janke 
Published: January 2024

Introduction: Multidisciplinary communication and collaboration are of utmost importance in order to transition from fragmented and disease-centered care to patient-centered care for people with multimorbidity. Interdisciplinary coordination of a care plan is a vital part of this collaboration, yet can take many different forms. Our primary aim is to uncover the existing pathways of multidisciplinary communication and collaboration to reach an integrated treatment plan. Our secondary aim is to identify potential limitations and strengths of these pathways, in order to propose ways to improve interdisciplinary coordination, and ultimately improve outcomes of care for patients with multimorbidity in the hospital.

Methods: Seven focus groups were organized, in both secondary and tertiary hospitals in the Netherlands. Each focus group was centered around a recent, local case study regarding a patient with multimorbidity. All involved health care professionals related to this specific patient were invited to participate in the focus group. Focus groups followed a discussion guide and were transcribed verbatim. Text was fragmented, coded  and thematized using the principles of grounded theory. Member checking was performed by experts in the field.

Results: 20 medical professionals were interviewed from three secondary, and four tertiary hospitals. None of the focus groups included all invited professionals due to their conflicting schedules. Analysis showed that the process of interdisciplinary coordination could be divided into the ‘reason’, ‘timing’, ‘modality’ and ‘outcome’. The ‘reason’ to seek interdisciplinary coordination could be medical complexity, a signal from a patient that indicates uncoordinated care, need for division of care roles, or to explore if care plans are aligned with the patient as a whole. Care providers could opt for different modalities to collaborate, such as: a phone call, referral to a colleague, or organizing a multidisciplinary team meeting. Possible outcomes could be integrating patient goals into the care plan, reduction in care consumption, and/or higher patient satisfaction. Factors of influence were identified for all main elements of this process: e.g. level of experience of the health care professional and available financial structures for different modalities of collaboration.

Implications: We introduce a process model describing the current pathways in multidisciplinary coordination of care for patients with multimorbidity. This model shows that depending on the reason to collaborate, and with the desirable outcome in mind, different modalities of collaboration and communication are possible. Using case studies, we illustrate how and where current pathways can fall short and new innovative ways of providing care can be developed. For the Netherlands, we are developing a new mode of seeking coordination based on this model which ensures better multidisciplinary collaboration and inclusion of the patient perspective: a structured multidisciplinary patient review (MPR) for patients with multimorbidity. We hope to inspire the international community to adapt this innovative model to their own context of care.