Introduction: Multi-morbid patients often need hospitalization due to worsening of their disease course. It means the care and treatment has to continue or end in another sector. There is therefore a need to strengthen the collaboration between the health care professionals.
The purpose of this study was to examine health professionals' suggestions for how to improve cross-sectoral collaboration that:
• Creates better cross-sectoral processes together with patient and relatives
• Increases patient`s and relatives` satisfaction with cross-sectoral processes
• Strengthen the cross-sectoral collaboration between the health professionals,
• Reduce the number of readmissions
Background: National and international research highlight how essential the cross-sectoral and interdisciplinary coordination and collaboration are when chronic and multi-morbid patients' care, treatment, and rehabilitation must be continued across sectors. In addition to insufficient coordination and cross-sectoral cooperation on the patient's course thus being unsafe for patients and their relatives; it can result in prolonged hospitalization and inappropriate (re) hospitalization. This has negative effects on the health care system as it adds to the general efficiency pressure from short and intensive hospitalization processes and care, treatment, and rehabilitation. Studies have shown that it remains a challenge to make cross-sectoral collaboration work across disciplines and sectors. In Denmark, the cross-sectoral collaboration consists of a municipal sector, general practitioners and a regional sector that includes hospitals and specialists .
When collaboration across the sector does not work, it becomes insecure for patients and their families. At the same time, an growing number of multi-morbid patients are in need of care, treatment, and rehabilitation which increase the requirements for both interdisciplinary and cross-sectoral coordination and collaboration.
The purpose of the study is through co-creation processes, to investigate health professionals, patients and relatives needs of collaboration to improve the safety and coherence of cross-sectoral courses.
Method: The overall design of the study is Action Research. Through four workshops, the Action Research Group consisting of researchers, health professionals, patients and relatives has co-created proposals which, in their assessment, could improve cross-sectoral collaboration. The workshops are audio-recorded and analyzed by the Action Research Group.
Results: the analysis points to five key themes to strengthen cross-sectoral cooperation:
1)understanding of the patient's course in the other sector 2) cross-sectoral knowledge and understanding of routine and work processes in the other sector 3) secure cross-sectoral communication 4) inclusion of patient and relatives in the collaboration 5) cross-sectoral collogue peer-fellowship.
Discussion: It is significant to all five proposals that they point to a community and intense co-operation between the health professionals. Overall, at a meta-level they point to a form of circular care, where it is emphasized that the participants must see the other as a collaborator, and as central actors who can not only take over the plan, but together develop the patient's course for the better. Chronic and multi-morbid people often require special knowledge and special skills of the health professionals - that is important to share across disciplines and sectors. There is therefore a need for knowledge sharing and re-thinking patients courses across sectors.