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A multimorbidity care model in primary care: a feasibility study


Hanne Birke

Center for Clinical Research and Prevention, Frederiksberg, DK
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The prevalence of multimorbidity is high in Denmark. Care provision in multimorbid patients is often fragmented, the quality of care is considered unsatisfactory, and patients experience a high disease and treatment burden. Organizational models for providing integrated care in multimorbidity exist, but with limited evidence of the effectiveness of specific interventions. The objective of this study was to assess the feasibility of an organizational model before evaluation in a cluster RCT-design.


The basic elements of the model are: prolonged consultations in general practice (a care manager; improved inter-sectorial communication through care plans; increased rates of referrals to rehabilitation in the community; medication review; and transfer of outpatient clinic controls to general practice. The model was implemented in a large general practice clinic in Copenhagen. Patients completed the ’The Patient Assessment of Chronic Illness Care (PACIC) and EuroQol 5-Dimension Questionnaire (EDQ5) questionnaires. Further, observation of consultations and focus group interviews with patients and professionals were performed to obtain information on important subjects such as patient-centeredness, level of integration of care, information flow, and medication satisfaction and safety.


Forty-eight patients with at least two of three selected chronic conditions (diabetes, heart disease, and COPD) were included. The mean age of the included patients was 72 years (48% men). At baseline, the mean total PACIC score was 2.7, with the highest subscale scoring for problem solving (3.3) and the lowest for coordination/follow-up (2.1). The EQ-5D-3L TTO index score and the EQ-5D-3L health status scale were 0.6 and 5.9, respectively.

From focus groups with patients, we identified a lack of treatment coordination; that prolonged consultations provided better coordination; and that patients wanted to be involved in treatment planning. Consultation observations and focus group interviews with health professionals pointed out communication barriers between general practice and outpatient clinics; emphasized the importance of patient-centered approaches to comprehend patients’ daily life problems; and elucidated prolonged consultations necessary for provision of high-quality care. Also, using the questionnaires in the consultation helped the GP to structure the dialog and improved the patient’s awareness and motivation for lifestyle changes.


Our study reveals that organizational innovations in general practice, such as prolonged consultations, patient involvement in decision making, and using a care manager to help with the planning of an individualized care plan seem to improve the multimorbid patient’s satisfaction with their treatment and care plan. Because of our small sample, the strength of our statistics is weak. As general practices in Denmark are heterogeneous, precautions should be taken regarding generalization of the conclusions. 

Conclusions/Lessons learned

The multimorbidity care model showed promising results. However, the model should undergo a focused revision before a larger RCT study. The development of feasible organizational innovations in existing health and social care systems is a task that requires improved collaboration and patient information-sharing between sectors in the healthcare system.

Suggestions for future research

RCTs investigating organizational collaboration between the healthcare sectors and patient involvement in order to improve the quality and the continuity of the treatment and care for multimorbid patients.

How to Cite: Birke H. A multimorbidity care model in primary care: a feasibility study. International Journal of Integrated Care. 2021;20(S1):83. DOI:
Published on 26 Feb 2021.


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