Year: 2025
Type: book-chapter
Abstract: Multimorbidity poses substantial challenges in healthcare, primarily due to the increasing need for coordinated care among patients with multiple chronic conditions. This study utilizes the Adjusted Clinical Groups (ACG) classification to segment patients into Patient Need Groups (PNG), advocating a shift from condition-based to patient-centered integrated care. Key elements include fostering stakeholder acceptance, advancing infrastructure to support care coordination, and transitioning to multi-condition national quality standards. The study begins developing and implementing PNG care programs at the hospital level, using this environment to refine clinical strategies tailored to multimorbid patients. Once the program demonstrates success, it will be expanded to the regional level, integrating services from healthcare providers such as primary care, specialists, and community services into a cohesive, integrated care program. Additionally, the regional expansion will explore the need of a regional information platform, to enhance communication and regional health record creation to support collaboration among healthcare providers and patients. The regional rollout will address systemic challenges, including optimizing resource allocation and aligning funding mechanisms with the new integrated care model. This may involve restructuring payment models to incentivize coordinated care, improve long-term outcomes, and support preventive services, ultimately creating an effective and sustainable care model for managing the health of patient populations. The primary goals are to improve care coordination and ensure that patients receive seamless, well-integrated care across various healthcare settings, with a strong emphasis on health maintenance.
DOI: 10.3233/shti250583
Authors: Jacob Hofdijk, Felix Cillessen
Institution: Ziekenhuis Rivierenland
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W4410447111