Fact sheet 06-2021

Improved coordination of health services

When health workers coordinated a person-centered and integrated health service around individuals, mortality among elderly, multi-morbid patients decreased by 43 per cent. For people with multiple conditions and needs, ordinary healthcare services can be life-threatening.

Western health services are doctor- and diagnosis-centered. It is designed for the patient to be able to go see a doctor, and then be treated for one illness at a time.

Most patients who have more than one disorder at the same time have experienced that they themselves must coordinate their health services across professions and levels of care.

Two thirds on 10 percent

The ordinary Norwegian health service has a fragmented information flow across different organizations and service levels and lacks holistic thinking. The health system also lacks a whole person focus.

Today the health service spends about two thirds of its resources on 10 per cent of the patients.

In these 10 per cent, we find many frail, multi-morbid elderly with complex needs. Such patients have a special need for a seamless health service where all participants communicate well with each other. If this is not available, the patient often becomes critically ill before receiving adequate treatment.

To overcome the challenge, the University Hospital of North Norway, together with four municipalities, started the project Patient-Centered Team (PACT) in 2014. The staff is made up of interdisciplinary personnel from primary care services and the hospital. They seek to improve the patient journey by making it patient-centred, integrated, and proactive.

The starting point is always to find out what really matters to the patient, and plan for what needs to be in place to meet the patient`s own goals. Then, in collaboration with the hospital, the home service, and others, they weave a safety net with treatment plans that are regularly reviewed and evaluated. An important aim is to prevent deterioration of clinical challenges. The team also carries out planned treatment and work to prevent emergency admissions to hospitals.

43 percent got a longer life

The researchers compared the results of patients who were referred to PACT, against a control group with patients who received ordinary patient care.

43 percent more of the patients who received person-centered, integrated and proactive health services in PACT were alive after six months.

In addition to the fact that mortality was significantly reduced, the research shows that the number of emergency admissions decreased by 10 per cent, and that the number of hospital days in connection with emergency help was reduced.

PACT will now be a service that is offered by more municipalities together with the University hospital in Northern Norway.

Reference:

Gro Rosvold Berntsen et al.: Person-centred, integrated and pro-active care for multi-morbid elderly with advanced care needs: a propensity score-matched controlled trial. BMC Health Services Research, 2019. Doi.org/10.1186/s12913-019-4397-2