Audhild Høyem

Systems for monitoring effectiveness and quality of rehabilitation services across health care levels are needed. The purpose of this study was to develop and pilot test a quality indicator set for rehabilitation of rheumatic and musculoskeletal diseases. The set was developed according to the Rand/UCLA Appropriateness Method, which integrates evidence review, in-person multidisciplinary expert panel meetings and repeated anonymous ratings for consensus building. The quality indicators were pilot-tested for overall face validity and feasibility in 15 specialist and 14 primary care rehabilitation units. Pass rates (percentages of “yes”) of the indicators were recorded in telephone interviews with 29 unit managers (structure indicators), and 164 patients (process and outcome indicators). Time use and participants’ numeric rating of face validity (0–10, 10 = high validity) were recorded. Nineteen structure, 12 process and five outcome indicators were developed and piloted. Mean (range) sum pass rates for the structure, process and outcome indicators were 59%(84%), 66%(100%) and 84%(100%), respectively. Mean (range) face validity score for managers/patients was 8.3 (8)/7.9 (9), and mean answering time was 6.0/5.5 min. The final indicator set consists of 19 structure, 11 process and three outcome indicators. To our knowledge this is the first quality indicator set developed for rehabilitation of rheumatic and musculoskeletal diseases. Good overall face validity and a feasible format indicate a set suitable for monitoring quality in rehabilitation. The variation in pass rates between centers indicates a potential for quality improvement in rheumatic and musculoskeletal rehabilitation in Norway.

In response to increase of patients with complex conditions, policies prescribe measures for improving continuity of care. This study investigates policies introducing coordinator roles in Norwegian hospitals that have proven challenging to implement. This qualitative study of policy documents employed a discourse analysis inspired by Carol Bacchi's 'What's the problem represented to be?'. We analysed six legal documents (2011-2016) and selected parts of four whitepapers presenting the statutory patient care coordinator and contact physician roles in hospitals. The 'problem' represented in the policies is lack of coherent pathways and lack of stable responsible professionals. Extended personal responsibility for clinical personnel as coordinators is the prescribed solution. Their duties are described in terms of ideals for coherent pathways across conditions and contexts. System measures to support and orchestrate the individual patient's pathway (e.g. resources, infrastructure) are scarcely addressed. We suggest that the policies' construction of the 'problem' as a responsibility issue, result in that neither diversity of patients' coordination needs, nor heterogeneity of hospital contexts regarding necessary system support for coordinators, is set on the agenda. Adoption of rhetoric from diagnosis-specific standardized pathways obscures unique challenges in creating coherent pathways for patients with complex needs.

Person-Centered Integrated Care (PC-IC) is believed to improve outcomes and experience for persons with multiple long-term and complex conditions. No broad consensus exists regarding how to capture the patient-experienced quality of PC-IC. Most PC-IC evaluation tools focus on care events or care in general. Building on others’ and our previous work, we outlined a 4-stage goal-oriented PC-IC process ideal: 1) Personalized goal setting 2) Care planning aligned with goals 3) Care delivery according to plan, and 4) Evaluation of goal attainment. We aimed to explore, apply, refine and operationalize this quality of care framework. This paper is a qualitative evaluative review of the individual Patient Pathways (iPP) experiences of 19 strategically chosen persons with multimorbidity in light of ideals for chronic care. The iPP includes all care events, addressing the persons collected health issues, organized by time. We constructed iPPs based on the electronic health record (from general practice, nursing services, and hospital) with patient follow-up interviews. The application of the framework and its refinement were parallel processes. Both were based on analysis of salient themes in the empirical material in light of the PC-IC process ideal and progressively more informed applications of themes and questions. The informants consistently reviewed care quality by how care supported/ threatened their long-term goals. Personal goals were either implicit or identified by “What matters to you?” Informants expected care to address their long-term goals and placed responsibility for care quality and delivery at the system level. The PC-IC process framework exposed system failure in identifying long-term goals, provision of shared long-term multimorbidity care plans, monitoring of care delivery and goal evaluation. The PC-IC framework includes descriptions of ideal care, key questions and literature references for each stage of the PC-IC process. This first version of a PC-IC process framework needs further validation in other settings. Gaps in care that are invisible with event-based quality of care frameworks become apparent when evaluated by a long-term goal-driven PC-IC process framework. The framework appears meaningful to persons with multimorbidity.

Introduction: Various efforts aim to enhance continuity of care for patients with long-term health-care needs. Since 2012, Norwegian hospitals are mandated to appoint individual care coordinators for patients with complex needs to ensure continuity in the care pathway. New roles must meld with current practice. Implementation has been slow. This study investigates current care coordination across hospital contexts, from the perspective of health-care providers, a scarcely researched area. Methods: A qualitative study using semi-structured individual, duo, and group interviews with 16 purposefully selected Norwegian health-care providers from different hospitals, departments, professions and with various roles. A thematic cross-case analysis using systematic text condensation was performed. Results: Common for the interviewees’ care coordination experiences was to “keep one step ahead.” The scope of their coordination activities varied from diagnostics and treatment to orchestrating long-term, cross-sectional multidisciplinary care. This work was often performed without designated resources. The interviewees applied experience, knowledge, and sensitivity when defining the patients’ needs and searching for resources to orchestrate coordination work. They strived to balance the needs of patients with the resources available and adjusted the continuity ambitions on behalf of their patients to what they considered doable in the relevant contexts. However, many told of negotiating special solutions for selected patients with particularly complex needs. Discussion: Care coordination for patients with complex needs emerged as diverse and context-sensitive. Acknowledgement of coordination activities that go beyond established workflow routines and clinical pathways, together with flexible leadership support and accessible infrastructural resources are needed.