Western societies are experiencing an epidemic of patients with multimorbidity. A prolonged medical history in a person with multiple conditions is fundamentally different to a more short-term episodic history. The treatment of long-term disease courses must increasingly include reference to the patient's personal needs, values and preferences and changes in these over time, alongside the development of a treatment plan that treats the patient's particular combination of diseases. Several studies suggest that these patients have worse outcomes and experiences than patients with less complexity, because services are often fragmented and uncoordinated.

Patient-centred health care teams (PACT) is a service model aimed at frail elderly patients with multiple long term conditions who are at risk of hospitalization, or where discharge planning is needed to establish early discharge support needs. The PACT model facilitates better care by providing: 1) structured patient-centred needs assessments, 2) individual care plans, and 3) a cross-functional team that coordinates services between specialised services and other units. The team includes expertise in the fields of geriatric nursing, physiotherapy, occupational therapy and medicine.


To investigate whether the PACT model improves health-related quality of life, health and function, in addition to a health-related economic evaluation and modelling. In addition, we ask patients to record the health-related limitations they experience, formulated as free-text. Records of Health Care Consumption are retrieved from specialist health care service and in local authorities and emergency care units.


Non-randomized, prospective, controlled study with a matched-pairs design. The intervention area is Tromsø and Harstad. Control patients will be recruited from Tromsø, Harstad and Narvik. Each index patient will be matched to a control of the same age, sex and level of resource consumption in the 2nd line service (total points the previous year according to the DRG patient classification system), which is a diagnosis-independent surrogate measure of morbidity.