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Background <p>Multimorbid and elderly patients generally turn to their general practitioners (GP) for social counseling. Community care points (CCP) are established local facilities that offer appropriate counselling.</p> Methods <p>In a&#xa0;feasibility study, cooperation between GPs and CCP was initiated and analyzed in two Berlin districts. During a&#xa0;15-month intervention phase, GPs were asked to refer multimorbid patients with social counseling needs to locally established CCP. Social consultations were categorized according to the reasons and outcomes documented on a&#xa0;previously developed ‘referral form’. Patient-related outcomes were collected and analyzed descriptively on the basis of a&#xa0;pre- and postCCP consultation assessment.</p> Results <p>Every patient (<i>n</i> = 63) who was ‘referred’ to a&#xa0;CCP by the GP (<i>n</i> = 10) received a&#xa0;comprehensive assessment of their actual need for counseling, irrespective of previously stated reasons for counseling. The majority of the participating patients were elderly, chronically ill and restricted in their daily activities. The vast majority met the criteria for depression, and many were lonely. After counseling at the CCP, more patients know who they can turn to in the future for social issues.</p> Conclusion <p>The participation rates of GPs and patients fell significantly short of expectations, which can be attributed to the project coinciding with the initial phase of the coronavirus disease 2019 (COVID-19) pandemic. Consequently, the results have to be interpreted with caution. Cooperation between GPs and CCP is obvious and feasible in view of neighboring care mandates. Multimorbid patients tend to suffer from depression and loneliness. GPs should inform these patients in need for social counseling about the services of CCP at an early stage.</p>

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Kooperation von hausärztlichen Praxen und Pflegestützpunkten für eine verbesserte soziale Versorgung multimorbider Patient*innen

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2025年4月7日

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  • Susanne Döpfmer,
  • Cornelia Wäscher,
  • Judith Stumm,
  • Lisa Peter,
  • Christoph Heintze

摘要

Background

Multimorbid and elderly patients generally turn to their general practitioners (GP) for social counseling. Community care points (CCP) are established local facilities that offer appropriate counselling.

Methods

In a feasibility study, cooperation between GPs and CCP was initiated and analyzed in two Berlin districts. During a 15-month intervention phase, GPs were asked to refer multimorbid patients with social counseling needs to locally established CCP. Social consultations were categorized according to the reasons and outcomes documented on a previously developed ‘referral form’. Patient-related outcomes were collected and analyzed descriptively on the basis of a pre- and postCCP consultation assessment.

Results

Every patient (n = 63) who was ‘referred’ to a CCP by the GP (n = 10) received a comprehensive assessment of their actual need for counseling, irrespective of previously stated reasons for counseling. The majority of the participating patients were elderly, chronically ill and restricted in their daily activities. The vast majority met the criteria for depression, and many were lonely. After counseling at the CCP, more patients know who they can turn to in the future for social issues.

Conclusion

The participation rates of GPs and patients fell significantly short of expectations, which can be attributed to the project coinciding with the initial phase of the coronavirus disease 2019 (COVID-19) pandemic. Consequently, the results have to be interpreted with caution. Cooperation between GPs and CCP is obvious and feasible in view of neighboring care mandates. Multimorbid patients tend to suffer from depression and loneliness. GPs should inform these patients in need for social counseling about the services of CCP at an early stage.