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Implementing a 'structured multidisciplinary care team' in Norway


Line Melby

Sintef, NO
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It is well known that persons with long term, complex needs need better coordinated and integrated services. In Norway, persons within this group have a legal right to an individual care plan (IP), and a coordinating team. However, fewer persons than those in the target group are offered such follow up. On this background, the Norwegian health authorities have issued new recommendations for how to follow up persons with long term complex care needs. These include  systematic assessment of care needs and establishment of a dynamic, small, multidisciplinary care team with a coordinator, so called "structured multidisciplinary care teams" (SMCT). User involvement is strongly emphasised.

In 2018, six municipalities across Norway ('pilot municipalities') received financial- and process support to implement the new recommendations by 2021. In a longitudinal research project, we  follow the pilot municipalities during the whole implementation period, and in this paper, we present findings from the first phase. The aim of the research has been to learn about how municipal service providers work and reshape work processes to detect and enroll all its inhabitants with long term complex care needs into SMCTs.


We conducted semi-structured interviews with employees in the six pilot municipalities (N= 175), as well as with users. In this paper, we only use data from interviews with employees. The interviewees comprise persons from healthcare, social work, child welfare, schools, kindergardens, and the Norwegian Labour and Welfare Administration, as well as clerical staff in the municipal administration. We also interviewed health and social top managers.


We found great diversity among the municipalities concerning follow up of persons with long term complex needs prior to the pilot project. All had good routines for the follow up of some groups (e.g. children, disabled persons), but all lacked a systematic and comprehensive approach for ensuring coordinated services for all groups in need of them. Common challenges were found across the municipalities in the first phase of the pilot. These included how to systematically identify persons in the target group, how to involve users in their own care team, and how to recruit, train and support coordinators.


Implementation of interventions of such a complexity is challenging, and we found that the municipalities need to start to work on a basic level with its organisation, routines, staff's skills and knowledge before they can start up with the SMCTs.


SMCTs can be useful arrangements for persons with long term complex care needs. However, providing all potential users with such teams requires new collaboration routines, systems for identifying users, and increased competence among providers.

Lessons learned:

SMCTs should be considered a complex intervention, implying that it is time consuming to implement them, and difficult to foresee all the effects.


The data is limited to the first part of the implementation process.

Suggestions for future research: Further research should provide knowledge on the variety of results from this way of organising follow up and care. 

How to Cite: Melby L. Implementing a 'structured multidisciplinary care team' in Norway. International Journal of Integrated Care. 2021;21(S1):59. DOI:
Published on 01 Sep 2021.


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