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. 2025 Mar;21(1):25-41.
doi: 10.1177/17423953231196611. Epub 2023 Sep 6.

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

Marlies Verhoeff  1   2   3 , Janke F de Groot  2 , Hanneke Peters-Siskens  4 , Erik van Kan  5 , Yolande Vermeeren  3 , Barbara C van Munster  1
Affiliations

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

Marlies Verhoeff et al. Chronic Illn. 2025 Mar.

Abstract

ObjectivesThis study aims to develop and pilot a hospital care coordination team intervention for patients with multimorbidity and identify key uncertaintiesMethodsPractice-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.ResultsOut 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.DiscussionRecruitment 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.

Keywords: Multimorbidity; care coordination; care coordination intervention; fragmented care; hospital care.

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Conflict of interest statement

Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Figures

Figure 1.
Figure 1.
Causal chain of care fragmentation. The potential primary and secondary patient- and care-related consequences of care fragmentation. Some secondary consequences can result in tertiary consequences as well.
Figure 2.
Figure 2.
Programme theory for a hospital care coordination team intervention with the patient-related, care-related and research-related activities, outputs and outcomes.
Figure 3.
Figure 3.
Flow chart of the patient selection and recruitment process.
See this image and copyright information in PMC

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