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Patient-Centred Healthcare Team

Authors:
Trine S Bergmo
Birgitte Aabotsvik
Monika Eriksen
Elisabeth Kollnes
Marte F Larsen
Hege Mathisen
Anne Grethe Olsen
Johanne Aasen
Monika Dalbakk
Grete Jakobsen
Torunn I Johansen
Stian Kristoffersen
Veronica Sørensen
Stine Haustreis

Keywords: Geriatrics, integrated care, patient centeredness, interdisciplinary teamwork, e-health, mobile health, safe discharge, avoided hospitalisation.

Abstract:
The University Hospital of North Norway and the Community Nursing Service in Tromsø Municipality established an integrated patient-centred care model to improve the continuity and quality of care for multimorbid older patients living in the region. The model includes a proactive interdisciplinary team providing outreach services supported by m-health technologies. The team consists of healthcare personnel from the Community Nursing Service and the hospital. The main aim is to help the patients get the needed hospital care, ensure safe discharge, provide support in the home environment, and prevent unnecessary hospital admissions. This paper describes the mobile team’s work practices and the information exchange process across two different levels of care. Furthermore, we analysed changes in treatment plans and estimated avoided hospitalisations. This is a prospective registration study supplemented with focus group discussions. This paper reports preliminary results from the first 98 patients the team handled.

Pages: 19 to 24

Copyright: Copyright (c) IARIA, 2016

Publication date: April 24, 2016

Published in: conference

ISSN: 2308-4359

ISBN: 978-1-61208-470-1

Location: Venice, Italy

Dates: from April 24, 2016 to April 28, 2016