Screening patients with complex multimorbidity in need of cross-sectoral coordination and collaboration. An Action Research approach.

People living with multi-morbidity experience reduced quality of life. They are highly dependent on a well-functioning integrated care across sectors. Lack of integrated care is the overarching theme experienced by people with multi-morbidity. Healthcare interventions and clinical guidelines are designed to focus on, and intervene for people with single conditions, thus leading to fragmented and sometimes even contradictory care for people with multi-morbidity. Not all patients with multi-morbidity need integrated care. Therefore, it is necessary to identify people who need integrated care for using resources best as possible. The aim of this study is to develop a stratification tool to identify elderly patients with complex multi-morbidity in need of extended coordination and integrated care.