Transforming Healthcare: A Norwegian Model for Person-Centered and Integrated Care for Patients with Complex Needs – Bridging Concept to Practice

Background: Demographic changes will lead to an increase in older, frail and complex patients. This places a high demand for health care systems and requires the care system to work more preventively, user-driven and coherently. For the most efficient use of scarce resources, it becomes important to identify patients with the greatest potential to benefit. Design, implementation and monitoring of the initiative: The patient group for this health care service are frail elderly people with complex long-term needs who face multiple care providers. These patients are especially vulnerable to care fragmentation. This group also dominates the 5-10% top spenders who account for 2/3 of high-level health care spending. Intervention: Akershus University Hospital, a 1098 beds hospital has with 5 associated municipalities developed a model for closer interdisciplinary care around the frail elderly with complex needs and high consumption of health care services. This model is called Integrated Health Care (IHC). We designed a computer application that uses deidentified health care data to identify risk patients based on age (>65) and number of emergency admissions the last six months (>3) spread over two or more different specialist departments. When a patient is included in IHC a multidisciplinary team (IHT-team) across primary and secondary care visits the patient at home. The IHC-team consists of a nurse and geriatrician from the hospital and a nurse and general practitioner from the municipality. In the conversation during the home visit, emphasis is placed on what is important to the patient. The team map risk areas and needs assistance. An individual treatment plan is created based on this conversation. The patient gets a contact person at the hospital and one in the municipality. If the patient is admitted to hospital, the IHC-team will receive an automatic notification and thus follow the patient during the hospital stay. Every 6 months there will be a follow-up conversation and opportunity to adjust the treatment plan. Results: The first patient was included in 2020 and so far 131 patients has been included, and the results are promising. The patients and their next of kin highlight the importance of a patient-centered approach. They report that the IHC-service provides an increased feeling of predictability and security. We have seen a major decrease in acute hospital admission for those patients included in the program. In the six months following inclusion, there was a notable decrease in average inpatient days for acute admissions, dropping from 61 to 20. There was also a noteworthy decline in the utilization of municipal emergency rooms. Short-term nursing home stays reduced from an average of 32 inpatient days before inclusion to 14 inpatient days after inclusion in IHC. Conclusion: The IHC method is effective in identifying patients at risk of frequent hospital admissions. Offering targeted and multidisciplinary services to frail patients seems to be effective in reducing acute admissions and use of health care services in the municipalities. Next steps: We're expanding the project to more municipalities and initiating a PhD project on the IHC model from 2024 onwards.