Chapter 1. General introduction
In the general introduction developments in the organization of healthcare delivery, were first described and followed by an outline of the thesis. The objectives were explained and the various chapters were briefly summarized.

Chapter 2. Integrated care for complex patients
This chapter described a systematic approach, the INTERMED method, to identify the risks of complex patients and their related integral needs, and discussed its applicability in relation to the nursing process. The major problem with existing care models is that, due to the fragmentation of care, it cannot be tailored to cope with the growing number of patients with multi-morbidity or with their long-term care needs. The INTERMED method is presented as a decision-support system. Based on the study results we stated that appropriate assessment of health risks, resulting in co-ordinated care with effective communication, is vital for multi-morbid patients, and there should also be a shift in focus from disease-oriented care towards medically complex and integrated care.

Chapter 3. Reliability of the INTERMED
In this study, the inter-rater reliability of the INTERMED was assessed by calculating the agreement of two independent raters, based on the same information. Correlations between the total scores of the two raters ranged from 0.91-0.96. At item level, in 83% of the assessments there were no differences between the raters, in 16% there was a 1-point difference, and in 1% there was a 2-point difference. Based on a cut-off score of 20/21, a κ of 0.85 was found. We concluded that there was a high agreement between the two experienced raters, and that after sufficient training it is possible to score the INTERMED reliably.

Chapter 4. Case management for complex patients: a systematic review
In the systematic review we summarized the available literature on the effectiveness of post-discharge case management for complex patients in general health care. We searched MEDLINE, EMBASE, the Cochrane Controlled Trials register and Cinahl for relevant publications, and identified 1638 articles, 10 of which met the inclusion criteria. The selection of the studies, the assessment of their methodological quality and the data-extraction were all carried out by two independent reviewers. The characteristics of the complex patients varied in the different studies. Although we defined our own criteria in the search for complex patients and case management programmes, there is still no widely accepted standard for the assessment of complexity.
There was considerable heterogeneity in the populations, interventions, duration of studies and outcomes, which made it impossible for us to perform a meta-analysis. We therefore decided to perform a best-evidence synthesis.
We found conflicting results, and we could therefore draw no firm conclusions. We found moderate evidence that case management has a positive effect on patient satisfaction, and we found strong evidence that case management has no significant effect on the number of visits to an emergency department. On the other outcomes (re-admission, days of hospitalization and quality of life) we found conflicting evidence. There was insufficient evidence that case management has a positive effect on a patient’s functional status.

Chapter 5. Implementing interventions: effects on quality of life and length of stay
In this intervention study we investigated the effects of a psychiatric intervention on patients in a general medical ward, in terms of improving their quality of life and reducing the length of hospital stay. One-hundred-and-ninety-three patients participated in a controlled trial, in which the patients were screened with COMPRI and INTERMED. A consultation liaison nurse conducted the interventions, which mainly consisted of psychiatric interventions, but also included of referral to auxiliary services, the organization of weekly multidisciplinary meetings or the initiation of post-discharge care. Intervention patients were compared with historic controls with regard to quality of life and length of stay. An overall positive effect on quality of life was found (p = 0.037), but this disappeared after controlling for confounders (p = 0.28). A reduction in length of stay was found for one sub-group, namely elderly patients (p = 0.006), but for the sample as a whole no significant effect was found (p = 0.72).

Chapter 6. Effectiveness of post-discharge case management
In this randomized clinical trial, the effects of a nurse-led case management intervention (NHI) on the number of emergency re-admissions and the level of care utilization, quality of life and psychological functioning 24 weeks after discharge was compared with care as usual. One-hundred-and-forty-seven patients were randomized, 69 to the control group and 78 to the NHI group. Patients in the intervention group were visited at home by a