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Multidisciplinary Care for Outpatients with Multiple Comorbidities

NOMINATED TOPIC | May 30, 2022

1. What is the decision or change (e.g. clinical topic, practice guideline, system design, delivery of care) you are facing or struggling with where a summary of the evidence would be helpful?

Health systems often struggle with delivery of urgent multidisciplinary care to outpatients. Is there evidence that the establishment of an acute care service for outpatients improves outcomes, decreases costs, prevents hospitalizations/re-hospitalizations and improves the patient experience?

2. Why are you struggling with this issue?

Many outpatients with multiple comorbidities have pressing clinical needs that cannot be solved with a single visit to their primary care physician. Sometimes they need urgent cardiology and pulmonary appointments, as well as a CT scan, lab work, echocardiogram, and physical therapy for example. While it is easy to get all this on the same day when they are admitted to the hospital, patients often struggle co ordinating their own timely care as outpatients.

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

I would like to see the establishment of an acute care service for outpatients with multiple active comorbidities who struggle to navigate the system on their own. The service or team could consist of a physician, a nurse, and a case manager or social worker. The service would accept referrals from the ED, inpatient discharge coordinator or even PCPs. Once the patient's acute needs have been addressed, the patient would then be turned back over to the care of their PCPs.

4. When do you need the evidence report?

Sat, 07/01/2023

5. What will you do with the evidence report?

If the evidence shows that this types of service improves the quality of care for patients, then I would advocate for its establishment in my hospital and other hospitals.

Optional Information About You

What is your role or perspective? Physician

May we contact you if we have questions about your nomination? Yes

Page last reviewed May 2022
Page originally created May 2022

Internet Citation: Multidisciplinary Care for Outpatients with Multiple Comorbidities. Content last reviewed May 2022. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.

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