The growing number of elderly patients with multiple chronic conditions places increasing pressure on healthcare systems. Despite reforms, fragmented communication between hospitals, municipalities, and general practitioners still compromises continuity of care. This paper reports findings from the Danish Virtual 4-Meetings (V4M) project, an action research initiative aimed at improving transitional care for patients with multimorbidity through structured, digitally supported collaboration.
Andersen et al. (Tue,) studied this question.