Abstract
INTRODUCTION: People with multimorbidity can experience fragmented healthcare and burden of treatment and the evidence-base for integrated care in multimorbidity is weak. The aim of this study was to develop a model for integrated care for patients with multimorbidity: The Primary Organization and Relations-Team (PORT). DESCRIPTION: The PORT prototype was formed using a co-production approach including workshops with healthcare professionals from hospital, general practice and municipalities, and interviews with patients with multimorbidity. The qualitative data were analyzed with systematic text condensation. During the co-production phase, 38 persons were interviewed or participated in workshops. Four themes emerged as central for integrated care for patients with multimorbidity: Information sharing, decision making across sectors, healthcare fragmentation, and patient-centeredness. A prototype aimed at these themes was developed and included continuous information sharing and case management by a joint specialty clinic, a total healthcare plan, and systematic needs assessment. DISCUSSION: The results and PORT prototype were developed through a comprehensive co-production process and the results and model may be transferred to other healthcare systems that are divided into sectors. CONCLUSION: Integrated multimorbidity care may be met through continuous information sharing, case management by a joint specialty clinic, a total healthcare plan, and systematic needs assessment.