The bridge to Öland from Kalmar

Project: Best practice of integrated care

Optimizing health and quality of life for people living with chronic complex conditions requires radically rethinking ways to coordinate care and support patients in self-management. The proposed project pioneers a powerful approach to address the challenge of rethinking care for people with complex care needs.

Project information

Title
Best practice of integrated care - Seamless care transitions and coordinated and safe care at home for people with complex care needs
Project manager
Mirjam Ekstedt, Cecilia Fagerström
Other project members
Heidi Hagerman, Ann-Therese Hedqvist, Susanna Strandberg, Catharina Lindberg, Monica Kaltenbrunner, Emelie Ingvarsson, Linnaeus University; Mia Von Knorring, Karolinska Institutet
Participating organizations
Linnaeus University; Karolinska Institutet
Financier
The Kamprad Family Foundation
Timetable
1 Sept 2019–30 Aug 2023
Subject
Caring Science and Health Science (Department of Health and Caring Sciences, Faculty of Health and Life Sciences)

More about the project

Optimizing health and quality of life for people living with chronic complex conditions requires radically rethinking waysto support patients in self-management. The proposed project pioneers a powerful approach to address the challenge of rethinking care for people with complex care needs.

By combining empirical evidence with both theoretical and experience-based evidence, this project has the opportunity to produce knowledge that is tailored to the particular circumstances or situation in which implementation is to take place

The overall aim of the project is to co-create, implement and evaluate multifaceted cross-organizational work processes and methods for seamless care transitions and coordinated and safe care at home for older adults with complex care needs and their significant others.

The projectme targets two main areas:
1) Seamless integration of care across organizational borders, and
2) Coordinated and safe care at home. Each area in turn consists of specific components, focused on coordinating interactions between professionals, as well as between professionals, patients and family caregivers, including introduction of digital solutions for remote monitoring and self-care support.

By studying how health care staff is doing to co-create care in current systems we can learn by the good examples of different solutions to develop personcentered work processes and digital solutions. In this way, continuity of care can be co-created and implemented to secure safe, seamless and individualized continuity of care for older adults with chronic care.

The project will contribute with knowledge about what factors impact: the older adults’ quality of life, symptoms and functionality; staff work satisfaction; and knowledge for health care providers contributing to increased care quality, time efficiency and optimal use of care.

The project is part of the research in The ReAction group – Resilient healthcare and patient activation research group and Linnaeus Knowledge Environment: Sustainable Health.

Staff