Collaboratively developing a stratification tool to screen patients with complex multimorbidity in need of cross-sectoral coordination. An Action Research approach.

Introduction: Patients living with complex multimorbidity have an increased risk of mental health problems, hospitalizations, reduced quality of life and premature death, and a high degree of care fragmentation, which is associated with higher rates of inappropriate medication and increased mortality. They are highly dependent on specialized and well-functioning integrated care and treatment across sectors, but often experience insufficient guidance from healthcare providers. However, little is known about how healthcare professionals may identify these patients in need of enhanced coordination. The aim: To develop a stratification tool for health professionals to screen patients on multimorbid complexity, in order to provide integrated care for those defined as ‘complex multimorbid’. Method: The stratification tool was developed through a collaboration between research and practice using an action research perspective. Through participation in dialogue-based workshops, it became possible for healthcare professionals (nurses and doctors), patients and their relatives, as well as researchers, to share knowledge and contribute to the development of the stratification tool. Thematic analyses emanating from field observations and qualitative interviews (n=18) served as the basis for two workshops focusing on: 1. Identification of complex multimorbid patients. 2. Idea generation and design development. Addressing topics of mutual concerns enabled all stakeholders to participate actively in the research processes with the aim of co-creating knowledge circulation, and qualification of knowledge production thereby contributing to greater cohesion and ownership between clinical practice, research, and the educational sector. Result: Six items were formulated to assess the complexity of the patient’s multimorbidity: 1) Hospitalizations and active outpatient process elements 2) Incapacity to return home following discharge 3) Cognitive challenges e.g. lack of overview, memory problems 4) Vulnerability e.g. previous or active abuse, sparse network, low self-care 5) Complex care needs 6) Explicit concern from patient and/or relatives related to each of the aforementioned domains. The stratification tool was developed acknowledging that complexity around multimorbidity cannot be accounted for in biomedical terms alone. Screening tools are often based on objective measurable units; however, in this stratification tool the professionals’ clinical assessments and professional judgment play a central role as well as the relatives' concern, which is taken into account in the final selection of patients at risk. Due to its focus on patient complexity as well as sector transitions, it differs from existing stratification tools using weighted and non-weighted scoring indices. Discussion and conclusion: The Action Research approach was an appropriate method to develop a stratification tool that may identify patients with complex multimorbidity. It is assumed that a correlation between higher complexity and an increased need for extended cross-sectoral coordination exists. Research following the JBI recommendation for scoping reviews is ongoing to identify and map the evidence for existing stratification tools. Future studies will seek to establish the validity and effectiveness of this tool for identifying complex multimorbid patients.