Development unit for more efficient care transitions

Important results from the project

There is a great need to develop care transitions, both from the patient and staff perspective. Effective information sharing is vital for seamless care transitions Routines are developed for distance meetings at the care transitions between region and municipality The new employment “coordinator service” was tested within the project and has resulted in a job description The “Biståndsbedömare” gains through the changed working methods and relief from “coordinator service”, the ability to follow his patient through the process and tools for an effective stay in the accommodation.

Expected long term effects

“Biståndsbedömarens” approach together with the coordinator means patient safety, individualized visit and shorter time on the accommodation. The information sharing via Cosmic link2 provides more effective meetings, where participants are prepared on the case. Distance meeting increased safty for the patient, and close relatives can be present from distance. The coordinator coordinates the patient´s needs in the accommodation and contact with the Health center and “biståndbedömaren”, which leads to a safer care transition to their own home and reduces re-admissions.

Approach and implementation

The project focus was the care crossing between the health care and the municipality accommodation to the patient home, where the Health center has the medical responsibility. Our goal was to create seamless health care crossing that provide increased safety for the patient and reduce re-admissions. The projects have noted a succeed through changed working methods, establishment of new employment role, conditions for distance meetings and use information sharing via Cosmic link2. There is a clear plan for what needs to be further develop in the process after the end of the project.