Programme no. 203-WS
Public Health
The continuity of care for older medical patients - Collaboration between general practice and other primary care services following hospital discharge
Anders Fournaise*1, Pia Therkildsen*2, Dorte Ejg Jarbøl*3, Pia Cecilie Bing-Jonsson*4, Gunnar Akner*5, Sonja Modin*6, Bente Overgaard Larsen*7
1Health, Cooperation and Quality,The Region of Southern Denmark,Vejle,Denmark;Department of Geriatrics,Odense University Hospital,Odense,Denmark;Research Unit of General Practice,University of Southern Denmark,Odense,Denmark, 2The Quality Improvement Committee for General Practice,The Region of Southern Denmark,Vejle,Denmark;Møllegade Medical Practice,Sønderborg,Denmark, 3Research Unit of General Practice,University of Southern Denmark,Odense,Denmark, 4Department of Nursing Science,Buskerud and Vestfold University College,Kongsberg,Norway, 5Scool of Health and Medical Sciences,Örebro University,Örebro,Sweden;Section of Clinical Geriatrics,Karolinska Institutet,Stockholm,Sweden, 6Centre for Family Medicine ,Karolinska Institutet,Stockholm,Sweden;Advisory board,The Swedish College of General Practice,Stockholm,Sweden, 7Department of Primary Care,The Region of Southern Denmark,Vejle,Denmark
* = Presenting author
Objectives: In this workshop we synthesize the experiences and practical knowledge on how general practice (GP) is or could be enabled to manage and collaborate with other primary care services on older medical patients following a hospital discharge.
Participants will acquire and share knowledge from Nordic frameworks and initiatives improving the continuity of care for older medical patients – and be inspired to develop or facilitate collaboration between GP and other primary care services in own local settings.
Background: The combination of an ageing society, a focus on efficient short-term hospital admissions and increasing ambulant care, calls for a closer collaboration between GP and primary care services. Despite of frameworks and initiatives implemented to ensure cross-sectorial collaboration it remains a challenge in everyday practice.
Content: 1. An overview of the evidence on how to manage the treatment of older medical patients in the primary care sector

2. How is evidence implemented in existing Nordic frameworks and initiatives?

- “The Older Medical Patient” – A Danish plan of action with a special focus on follow-up visits and coordination after hospital admission.

- “The Web Control Protocol” – A Swedish initiative aimed at developing coordinated health and social care.

W Case based group work on how an older medical patient would be managed in the Nordic countries at present.

3. Cooperation and communication between GP and other primary care services

- Competences of home care personnel in relation to managing older medical patients and their communication with GP.

- The perceived impact of a well functioning collaboration and communication in the primary care sector regarding treatment and rehabilitation of older medical patients.

W 'World café' on challenges and barriers in communicating and cooperating in the primary care sector.

4. Future needs and development

- Summarizing key points of the workshop

Method: We aim at a high level of participant involvement. The workshop will consist of oral presentations, dialogue and reflection in smaller groups and plenum.
Other considerations: Participants will be invited to sign up for a writing group with the purpose of reviewing and publishing a peer-reviewed article on well functioning collaboration and initiatives aimed at high quality continuity of care for older medical patients in the Nordic countries.