Konferencebidrag 4. NOV 2022
Design af virtuelle fire-parts møder: inddragelse af patienter med multisygdom og deres pårørendes ønsker og mål i video-medieret tværsektoriel samarbejde
Udgivelsens forfattere:
- Helle Sofie Wentzer
- Ditte Merete Høgsgaard
- Sundhed
- Ældre Sundhed, Ældre
Wentzer H.S et al, 2022 D. International Journal of Integrated
Care 22(S3):236 DOI: doi.org/10.5334/ijic.ICIC22236
Introduction: Virtual four-part Meetings, V4M is a Danish Research Project in the Region of
Zealand. This action-research-based project intervenes in the patient care pathways of frail
elderlies and multimorbid patients in the intersection of municipality care and hospitalization. The
purpose of the project is to i) Create a mutual understanding between primary care and secondary
care actors, ii) include the patient’s wishes and relatives in shared decision-making, and iii)
Develop a cross-sectorial infrastructure of communication that supports dialogue between the
central stakeholders of multimorbid patients’ care pathways.
Background: Elderly patients with multimorbidities are prone to (re)admissions to hospital. They
are highly dependent on intersectional collaboration between municipality care, home, GP, and
specialist hospital treatment – “the 4” parties necessary for continuity and quality of treatment and
care. These four parties are located in geographically and organizationally dispersed settings, which
challenges their exchange of information and communication and is thus a barrier to their
collaboration and development of shared plans of action. Further innovative cross-sectoral and
interdisciplinary collaborations are urgently called for, as the demographics of the region indicate
a substantial future increase of elder citizens with many care needs. The vision is to create a stable
environment for multimorbid patients with circular care pathways through holistic, interdisciplinary,
video-mediated collaborations that include the patients and relatives’ wishes.
Method: Designing of interorganizational video guidelines: The project tests virtual meetings
between the four parties at two passage points of the patient care pathways: i) when frail elderly
persons are admitted to hospital to ensure a shared understanding of the patients’ needs, and ii)
when patients are discharged to municipality care to safeguard the transition and continuity of
care. A communication guide for video meetings between the four parties is developed by the action
research group. The group is interdisciplinary with participants from each of the organizational
settings, i.e., the home, representing the patient’s and relatives’ perspectives, the GP, representing
the perspective of the GP’s clinic, the municipality, including the perspectives of care and
rehabilitation, and the hospital, especially nurses and doctors with specialties in cardiology and
geriatrics. Twenty V4Ms are conducted, with follow-up qualitative interviews of patients/relatives
and health professionals, evaluation workshops, time-registration forms and questionnaires, and
subsequently content and in-depth data analysis.
Results: The preliminary findings from Virtual-4-meetings with hospitalized elderly persons point
to the following outcomes:
•the negotiation of differences in their horizons of understanding
Wentzer: Designing Virtual-4-Meeting: aligning multimorbid patients’ and relatives’ wishes and goals in video-mediated crosssectoral collaborations
•new levels of collectively learning
•shared decision making that empowers each part on their prospective tasks and responsibilities
•adjusted and coordinated actions
•the patient’s experience of an improved care path-circuit between the sectors.
•more efficient citizen-centered solutions.
Conclusion: The findings show that, given a stable technical infrastructure and organizational
resources to plan and participate in V4M it is possible to align the patient’s wishes and care plans
in joint action. Virtual meetings thus transcend the organizational boundaries of hospital,
municipality, GP, and the home, and create a new, cross-sectional context of learning and
understanding that potentially benefits the quality of care.
Care 22(S3):236 DOI: doi.org/10.5334/ijic.ICIC22236
Introduction: Virtual four-part Meetings, V4M is a Danish Research Project in the Region of
Zealand. This action-research-based project intervenes in the patient care pathways of frail
elderlies and multimorbid patients in the intersection of municipality care and hospitalization. The
purpose of the project is to i) Create a mutual understanding between primary care and secondary
care actors, ii) include the patient’s wishes and relatives in shared decision-making, and iii)
Develop a cross-sectorial infrastructure of communication that supports dialogue between the
central stakeholders of multimorbid patients’ care pathways.
Background: Elderly patients with multimorbidities are prone to (re)admissions to hospital. They
are highly dependent on intersectional collaboration between municipality care, home, GP, and
specialist hospital treatment – “the 4” parties necessary for continuity and quality of treatment and
care. These four parties are located in geographically and organizationally dispersed settings, which
challenges their exchange of information and communication and is thus a barrier to their
collaboration and development of shared plans of action. Further innovative cross-sectoral and
interdisciplinary collaborations are urgently called for, as the demographics of the region indicate
a substantial future increase of elder citizens with many care needs. The vision is to create a stable
environment for multimorbid patients with circular care pathways through holistic, interdisciplinary,
video-mediated collaborations that include the patients and relatives’ wishes.
Method: Designing of interorganizational video guidelines: The project tests virtual meetings
between the four parties at two passage points of the patient care pathways: i) when frail elderly
persons are admitted to hospital to ensure a shared understanding of the patients’ needs, and ii)
when patients are discharged to municipality care to safeguard the transition and continuity of
care. A communication guide for video meetings between the four parties is developed by the action
research group. The group is interdisciplinary with participants from each of the organizational
settings, i.e., the home, representing the patient’s and relatives’ perspectives, the GP, representing
the perspective of the GP’s clinic, the municipality, including the perspectives of care and
rehabilitation, and the hospital, especially nurses and doctors with specialties in cardiology and
geriatrics. Twenty V4Ms are conducted, with follow-up qualitative interviews of patients/relatives
and health professionals, evaluation workshops, time-registration forms and questionnaires, and
subsequently content and in-depth data analysis.
Results: The preliminary findings from Virtual-4-meetings with hospitalized elderly persons point
to the following outcomes:
•the negotiation of differences in their horizons of understanding
Wentzer: Designing Virtual-4-Meeting: aligning multimorbid patients’ and relatives’ wishes and goals in video-mediated crosssectoral collaborations
•new levels of collectively learning
•shared decision making that empowers each part on their prospective tasks and responsibilities
•adjusted and coordinated actions
•the patient’s experience of an improved care path-circuit between the sectors.
•more efficient citizen-centered solutions.
Conclusion: The findings show that, given a stable technical infrastructure and organizational
resources to plan and participate in V4M it is possible to align the patient’s wishes and care plans
in joint action. Virtual meetings thus transcend the organizational boundaries of hospital,
municipality, GP, and the home, and create a new, cross-sectional context of learning and
understanding that potentially benefits the quality of care.
Udgivelsens forfattere
- Helle Sofie WentzerDitte Merete Høgsgaard
Om denne udgivelse
Publiceret i
International journal of integrated care