Report 31. AUG 2022
Cross-sectoral video meetings on the care pathway of the frail, older patient
Authors:
- Helle Sofie Wentzer
- Ditte Merete Høgsgaard
The Elderly
Management and implementation
The Social Sector
Children, Adolescents and Families
Health Care
The Elderly, Management and implementation, The Social Sector, Children, Adolescents and Families, Health Care

Cross-sectoral video meetings on the care pathway of the frail, older patient
A manual for holding virtual four-party meetings about extended coordination, “V4M”, between hospitalised older patients, family members, hospital, municipality and general practitioner
The Danish Center for Social Science Research (VIVE) and Primary and eHealth Care Region Zealand have together developed a manual for how a video meeting between hospital, municipality, general practitioner, and the patient and their family can lead to a joint care and support plan.
Four-party video meetings (V4M) between hospital, municipality, general practitioner, and the patient and their family hold the potential to improve patient safety and the quality of cross-sectoral pathways for older patients. V4M are aimed at hospitalised older patients receiving municipal care and support who have multiple diagnoses and are frequently hospitalised for longer periods. The video meeting creates a shared space in which the involved parties can clarify the patient’s overall condition and agree on a common objective for treatment as well as a joint care and support plan.
Cross-sectoral collaboration on older medical patients with multiple diseases is a challenge for the healthcare system as well as the patients themselves and their families. And this challenge will only grow and become more pressing in line with the number of older people increases in a soceity with limited resources. Video meetings betweem patients and their family, hospital and municipal stakeholders and the patient’s GP enable coordination of the patient’s many care and treatment contexts and their everyday life. The meeting is based on the question: What is important for you? — . This question invites the patient and their family to share their concerns and encourages healthcare professionals to contribute with their knowledge and suggestions for a joint care and support plan. The Novo Nordisk Foundation, Studies on integrated care pathways, has financed the project.
V4M is aimed at the small group of hospitalised patients older than 80 who are caught in a cycle of admission and discharge and are thus in constant need of care and treatment in both sectors. The video meeting enables 'extended coordination’ of the older person’s pathway. Analysis of 11 video meetings revealed 12 themes, for example, medication and functional level, that are included in the assessment of how stable the patient is and that make it possible to set goals for the patient and agree on a care and support plan, including who is to do what. A finding was also the general practitioner's commitment and active participation in V4M. In one-third of the video meetings, the patient, their GP and the municipality agreed on a follow-up home visit after the patient’s discharge from hospital. In subsequent interviews, patients and their family expressed that they were happy with the V4M and the feeling of safety this meeting gave them: “that everyone has heard the same things”. Because of the meeting, the parties had a better understanding of the differences between their sectors and professions, the interests of the patient’s family as well as the patient’s joint care and support plan.
The project has led to three communication products, which are attached to the report (annex). These communication products can be used when organising and conducting cross-sectoral four-party video meetings.
A manual for holding virtual four-party meetings about extended coordination, “V4M”, between hospitalised older patients, family members, hospital, municipality and general practitioner
The Danish Center for Social Science Research (VIVE) and Primary and eHealth Care Region Zealand have together developed a manual for how a video meeting between hospital, municipality, general practitioner, and the patient and their family can lead to a joint care and support plan.
Four-party video meetings (V4M) between hospital, municipality, general practitioner, and the patient and their family hold the potential to improve patient safety and the quality of cross-sectoral pathways for older patients. V4M are aimed at hospitalised older patients receiving municipal care and support who have multiple diagnoses and are frequently hospitalised for longer periods. The video meeting creates a shared space in which the involved parties can clarify the patient’s overall condition and agree on a common objective for treatment as well as a joint care and support plan.
Cross-sectoral collaboration on older medical patients with multiple diseases is a challenge for the healthcare system as well as the patients themselves and their families. And this challenge will only grow and become more pressing in line with the number of older people increases in a soceity with limited resources. Video meetings betweem patients and their family, hospital and municipal stakeholders and the patient’s GP enable coordination of the patient’s many care and treatment contexts and their everyday life. The meeting is based on the question: What is important for you? — . This question invites the patient and their family to share their concerns and encourages healthcare professionals to contribute with their knowledge and suggestions for a joint care and support plan. The Novo Nordisk Foundation, Studies on integrated care pathways, has financed the project.
V4M is aimed at the small group of hospitalised patients older than 80 who are caught in a cycle of admission and discharge and are thus in constant need of care and treatment in both sectors. The video meeting enables 'extended coordination’ of the older person’s pathway. Analysis of 11 video meetings revealed 12 themes, for example, medication and functional level, that are included in the assessment of how stable the patient is and that make it possible to set goals for the patient and agree on a care and support plan, including who is to do what. A finding was also the general practitioner's commitment and active participation in V4M. In one-third of the video meetings, the patient, their GP and the municipality agreed on a follow-up home visit after the patient’s discharge from hospital. In subsequent interviews, patients and their family expressed that they were happy with the V4M and the feeling of safety this meeting gave them: “that everyone has heard the same things”. Because of the meeting, the parties had a better understanding of the differences between their sectors and professions, the interests of the patient’s family as well as the patient’s joint care and support plan.
The project has led to three communication products, which are attached to the report (annex). These communication products can be used when organising and conducting cross-sectoral four-party video meetings.
Authors
- Helle Sofie WentzerDitte Merete Høgsgaard
About this publication
Financed by
Novo Nordisk FondenCollaborators
Det Nære Sundhedsvæsen, Region SjællandPublisher
VIVE - Det Nationale Forsknings- og Analysecenter for Velfærd