More efficient care process with support for proactive self-care

Purpose and goal

The aim is to identify the system gaps that arise in the care process in home healthcare for patients with complex care needs, especially in the transitions between specialist care, primary care, ASIH and municipal care. The goal is to explore and develop concrete proposals for how the gaps can be prevented through increased collaboration between care organizations and a more proactive, person-centered and cohesive care at home.

Expected effects and result

The project will develop concrete proposals on how the gaps identified in the home healthcare process can be prevented. In short term, this will strengthen the patient´s security, participation and ability to self-care at the same time as healthcare resources can be used more efficiently. In long term, the proposals will strengthen the healthcare system´s conditions to meet challenges of the future, with an increased number of patients, with the same number of healthcare staff and hospital beds.

Planned approach and implementation

Patients with heart failure are recruited via Riksförbundet HjärtLung Stockholms County, and via Karolinska and SLSO (primary care) that monitors patients at home. Several workshops will be held where patient representatives with experience from more complex care processes are involved together with other relevant care actors such as doctors and nurses from Karolinska, primary care and ASIH. Workshops will be conducted for data collection, analysis of collected data and processing of results.