Good patient pathways for older people

Background: Over 50 million people in Europe suffer from more than one chronic condition (multimorbidity). "Learning network for good patient care" is a national program aimed at vulnerable elderly people who receive municipal home care services including short-term stays in nursing homes. A coordinator (nurse, assistant nurse) maps the patient's functional level and wishes for goal achievement, targeted everyday rehabilitation, coordination with the patient's GP and other relevant health and social services.

Purpose: to evaluate whether the Learning Network for Good Patient Pathways helps improve patient health and well-being, and reduces costs.

Method: prospective cohort study with control group. Based on a questionnaire survey among about 100 patients in 12 municipalities participating in the Learning Network, and about 100 patients from 4 municipalities who do not (yet) participate in the Learning Network. Data collection is done twice, baseline (when the patient receives new municipal services) and after 6 months.