Care for older patients with combined severe mental and physical illness:development, implementation and evaluation of a transmural care pathway.

More than two-third of elderly patients attending psychiatric services have at least one physical illness, and many have at least two. Effective management of multimorbidity requires integration of physical and mental healthcare. Geriatric co-management programs might be a potentially (cost-)effective model for collaborative care in joint geriatric/gerontopsychiatric wards, and for home-based multidisciplinary psychiatric care services. The aim of this project is to develop, implement and evaluate a transmural care pathway for older patients with combined severe mental and physical illness. Therefore, the 7-phase method will be applied, consisting of a screening phase, a project management phase, a diagnostic- and objectification phase, a development phase, an implementation phase, an evaluation phase, and a continuous follow-up phase. The result of this project will be a transmural care pathway,piloted in an in-hospital and primary care setting in Leuven. This will form the basis for future upscalingprojects.

Keywords:Geriatrics, Psychiatry, Collaborative care, Psych/med unit, Transmural care

Disciplines:Psychiatry and psychotherapy not elsewhere classified, Gerontology and geriatrics not elsewhere classified