Innan en patient som bedöms vara i behov av insatser från kommunens socialtjänst eller annan öppenvård med mera skrivs ut från slutenvården måste en vårdplanering utföras. Vårdplaneringen utförs av patientansvarig sjuksköterska tillsammans med ett antal representanter från öppenvården. Syftet med studien är att belysa hur sjuksköterskor inom landstinget upplever samordnad vårdplanering. Metoden som användes var en kvalitativ enkätundersökning. Resultatet baseras på tio enkäter ifyllda av sjuksköterskor på lungmedicin på KSS i Skövde. Dessa enkätsvar gick sedan igenom en kvalitativ innehållsanalys för att urskilja upplevelser hos sjuksköterskorna. I resultatet framkom att sjuksköterskorna upplevde stress, frustration, dåligt samvete samt bristande samarbete men att sjuksköterskorna accepterade situationen och jobbade vidare. / A coordinated care plan must be carried out before a patient in closed care, that need help from the municipality social services or other open care institutions, can be discharged. This coordinated care planning is accomplished by a team consisting of the nurse responsible for the patient together with a number of representatives from the municipal care. The aim with the study is to elucidate how nurses within the county council experience the coordinated care planning. The method used in this study was a qualitative questionnaire survey and the answers were assessed by using a qualitative content analysis. The results are based on ten questionnaires answered by nurses working at the lung medicine ward in Kärnsjukhuset, Skövde. This study revealed that the nurses experienced stress, frustration, bad conscience and inadequate cooperation in the coordinated care planning; however, they accepted the situation and kept on working.

<p>Innan en patient som bedöms vara i behov av insatser från kommunens socialtjänst eller annan öppenvård med mera skrivs ut från slutenvården måste en vårdplanering utföras. Vårdplaneringen utförs av patientansvarig sjuksköterska tillsammans med ett antal representanter från öppenvården. Syftet med studien är att belysa hur sjuksköterskor inom landstinget upplever samordnad vårdplanering. Metoden som användes var en kvalitativ enkätundersökning. Resultatet baseras på tio enkäter ifyllda av sjuksköterskor på lungmedicin på KSS i Skövde. Dessa enkätsvar gick sedan igenom en kvalitativ innehållsanalys för att urskilja upplevelser hos sjuksköterskorna. I resultatet framkom att sjuksköterskorna upplevde stress, frustration, dåligt samvete samt bristande samarbete men att sjuksköterskorna accepterade situationen och jobbade vidare.</p> / <p>A coordinated care plan must be carried out before a patient in closed care, that need help from the municipality social services or other open care institutions, can be discharged. This coordinated care planning is accomplished by a team consisting of the nurse responsible for the patient together with a number of representatives from the municipal care. The aim with the study is to elucidate how nurses within the county council experience the coordinated care planning. The method used in this study was a qualitative questionnaire survey and the answers were assessed by using a qualitative content analysis. The results are based on ten questionnaires answered by nurses working at the lung medicine ward in Kärnsjukhuset, Skövde. This study revealed that the nurses experienced stress, frustration, bad conscience and inadequate cooperation in the coordinated care planning; however, they accepted the situation and kept on working.</p>

This study explored how being enrolled in a program that both coordinates patient care and provides a medical home changes health care utilization for uninsured patients, more specifically those persons with chronic conditions, through the use of the Chronic Care Model and Andersen and Aday’s Behavioral Model for Access to Health Care. Uninsured patients typically seek out care in a fragmented manner, which may lead to ineffective and inefficient care, especially for conditions that may require ongoing treatment and monitoring such as chronic conditions. The methodology used to examine the relationship between the interaction of enrollment and chronic condition status and health care utilization was multivariate linear regression. The results of this study show that enrollment in a coordinated care program does have an impact on health care utilization, and that the impact differs for patients with no chronic conditions, a single chronic condition, and multiple chronic conditions. These results point to the effectiveness of implementing the Chronic Care Model to improve access to health care for patients with chronic conditions.

Yes / Community-based case managers in health have been compared to glue which holds the dynamic needs of clients to a disjointed range of health and social services. However, case manager roles are difficult to understand due to poorly defined roles, confusing terminology, and low visibility in New Zealand. This review aims to map the landscape of case management work to advance workforce planning by clarifying the jobs, roles, and relationships of case managers in Aotearoa New Zealand (NZ). Methods: Our scoping and mapping review includes peer-reviewed articles, grey literature sources, and interview data from 15 case managers. Data was charted iteratively until convergent patterns emerged and distinctive roles identified. Results: A rich and diverse body of literature describing and evaluating case management work in NZ (n = 148) is uncovered with at least 38 different job titles recorded. 18 distinctive roles are further analyzed with sufficient data to explore the research question. Social ecology maps highlight diverse interprofessional and intersectoral relationships. Conclusions: Significant innovation and adaptations are evident in this field, particularly in the last five years. Case managers also known as health navigators, play a pivotal but often undervalued role in NZ health care, through their interprofessional and intersectoral relationships. Their work is often unrecognised which impedes workforce development and the promotion of person-centered and integrated health care. / This research was funded by the AUT University, Faculty of Health & Environmental Sciences Summer Student Grant 2021/2022 and the School of Public Health and Interdisciplinary Studies PBRF Funding 2021. The APC charge is covered by the School of Public Health and Interdisciplinary Studies PBRF 2022.

Bakgrund: Vi blir allt äldre och fler bor kvar i hemmet med behov av vård- och omsorgsinsatser. Då dessa personer av någon anledning vårdats på sjukhus och skall återgå till hemmet görs en vård- och omsorgsplanering för att patienten ska kunna lämna slutenvården på ett tryggt sätt. Med ett växande antal äldre med behov av insatser i hemmet kommer även behovet av samordnad vård- och omsorgsplanering på sjukhus att öka. En sådan planering görs allt mer via videokonferens idag. Denna form av digitala möten innebär nya utmaningar för sjuksköterskan i att skapa och upprätthålla en ömsesidighet. Syfte: Syftet med studien var att undersöka förutsättningar för vård- och omsorgsplanering via videokonferens och hur detta påverkar möjligheten för vårdpersonalen att kunna förstå och tolka patientens situation utifrån ett helhetsperspektiv och således utföra ett personcentrerat möte på distans. Metod: En kvalitativ forskningsansats användes för att erhålla en förståelse av sjuksköterskors erfarenhet av vård- och omsorgsplanering via videokonferens. Metoden bestod av en inledande explorativ litteraturstudie samt enskilda personliga semistrukturerade intervjuer. Urvalet bestod av totalt sju sjuksköterskor inom slutenvård, primärvård och kommunal hemsjukvård. Analysen av intervjumaterialet utfördes med en induktiv ansats inspirerad av fenomenologi. Resultat: Resultatet visar att kommunikationen påverkas och att möten via videoteknik förlorar närhet och således en del av den mänskliga kontakten. Detta kan bidra till sämre möjlighet att se varandra som personer men kan kompenseras av ett personcentrerat förhållningssätt. Tekniken kan fungera som ett medel för mänsklig interaktion dock ej ersättning för det. Huvudtemana som framkommer i resultatet är förlust av närhet kompenseras av flera vinster med tillhörande teman skärmen som barriär och vinster för vårdpersonal, patient och anhöriga samt teknik som medel för mänsklig interaktion med tillhörande teman ytterst beroende av personerna i mötet och hög kvalitet på utrustning och prestanda. Slutsats: Samordnad vård- och omsorgsplanering via videokonferens innebär utmaningar i att skapa närvaro och ett genuint intresse som kompenserar för den fysiska närhet som förloras. Denna mötesform kan göra det svårare se varandra som personer men detta hinder kan kompenseras av ett personcentrerat förhållningssätt. Sjuksköterskan behöver vara väl förtrogen med personcentrerad vård för att kunna möta patienten trots den barriär som skärmen kan utgöra. Teknik är ett medel, inte ett självändamål i sig. Rätt nyttjad kan informations- och kommunikationsteknologi användas med stora tidsvinster för att få tillgång till varandra oavsett geografisk plats och kan bidra till en mänsklig interaktion men inte ersätta den. / Background: We are becoming older and more people remain in their home with the need for care. When these persons for some reason have been hospitalized and are to return to their homes, care planning is performed in order for the person to be able to leave the ward in a safe manner. With an increasing number of elderly persons in need of care interventions in their home, the need for coordinated care planning in hospitals will also increase. Such planning is today being performed increasingly often via video conferencing. This form of digital encounters poses new challenges for the nurse in creating and maintaining a mutuality. Aim: The aim of the study was to investigate the conditions for coordinated care planning via video conferencing and how this affects the ability of health care professionals to understand and interpret the patient’s situation from a holistic perspective, thus performing a person-centered meeting at a distance. Method: A qualitative research approach was used to gain an understanding of nurses' experience of coordinated care planning via video conferencing. The method consisted of an initial exploratory literature study and individual personal semistructured interviews. The sample consisted of a total of seven nurses in primary care, primary care and municipal home nursing. The analysis of the interview material was conducted with an inductive approach inspired by phenomenology. Result: The result shows that the communication is affected and that meetings via video technology lose proximity and thus a part of the human contact. This can disrupt the possibility of seeing each other as persons but can be compensated by a person-centered approach. The technology can act as a means of human interaction, but not as a compensation for it. The main themes found in the result are loss of proximity compensated by multiple gains with associated themes screen as a barrier and benefits for healthcare professionals, patients and relatives as well as technology as means of human interaction with associated themes decidedly dependent on the people in the meeting and high quality in equipment and performance. Conclusion: Coordinated care planning via video conferencing involves challenges in conveying presence and genuine interest that compensates for the loss of physical presence. This form of meeting can make it more difficult to see each other as persons, however this obstacle can be compensated by a person-centered approach. The nurse needs to be well acquainted with person-centered care in order to meet the patient despite the barrier that the screen may create. Technology is a means, not an end in itself. Proper use of information and communication technology can be used with great time gains to access each other regardless of geographical location and can contribute to human interaction but not replace it.

Background: Previous studies have shown that an integrated care approaches for older people with complex care needs comes with less hospitalization and the reduced cost for the community (Eklund &amp; Wilhelmssons, 2009). Since the new reform about coordinated care (2017:612) took place higher demand was put on the professionals in the health care system to collaborate. The reform indicates that a coordinated care plan should be establish to people with complex care needs when they go from in- to outpatient care (SKR, 2018) Aim: To describe health professionals in municipality, institutional care and primary experience of coordinated care plans to older people with complex care needs and describe their opinion of which elements that facilitated and embarrass the process.Method: The study was conducted whit a qualitative study design in form of interviews. Nine respondents were included in the study. A content analysis with a deductive approach was used (Elo &amp; Kyngäs’s. 2018). Widmarks et al; s (2011) model was used as a theoretical framework.Result: The key factors: allocation of responsibilities, confidence and the professional encounter was found in the analyses. And there were areas in al of them were barriers to collaboration occurred and made collaboration difficult. Conclusion: The result indicates that there is a lack of clarity due to the guidelines of the collaboration process. These guidelines must be improved to facilitate collaboration for older people with complex care needs.

Bakgrund: Vi blir idag allt äldre. Ett ökande antal äldre med komplexa vårdbehov kräver en samordnad vård utifrån ett helhetsperspektiv med patienten som person i centrum. En samordnad vårdplanering genomförs på sjukhuset före utskrivning för att samordna hälso- och sjukvård från sjukhus, primärvård och kommunal vård. Dessa vårdplaneringar utförs idag ofta via videomöte. För att upprätthålla en personcentrerad vård och främja en trygg och säker hemgång, behöver vårdplaneringen genomföras på ett sådant sätt att den äldre upplever delaktighet och därmed kan påverka beslut kring sin egen vård och hälsa. Syfte: Syftet med studien var att beskriva samordnad vårdplanering via videomöte ur den äldre personens och närståendes perspektiv. Metod: En induktiv kvalitativ forskningsansats användes genom åtta personliga ostrukturerade intervjuer. Ett strategiskt urval gjordes som resulterade i fyra äldre personer, Md=79 år, (70-83), samt fyra närstående, Md=54 år, (45-58). Inklusionskriterier var erfarenhet av vårdplanering via videomöte och för de äldre en ålder på minst 70 år. Materialet analyserades med kvalitativ innehållsanalys. Resultat: Den äldre personens och närståendes upplevelse av vårdplanering via videomöte kan beskrivas av temat att befinna sig i ett utanförskap. Detta baseras på tre kategorier utifrån upplevelse av opersonlighet, meningslöshet samt bristande delaktighet. Otillräcklig förberedelse eller information kan skapa en känsla av utanförskap som riskerar hindra möjligheten till delaktighet, inflytande och medbestämmande i vården. Slutsats: Samordnad vårdplanering via videomöte kan möjligen bli en tillfredsställande mötesform även för äldre. Flera utmaningar och svårigheter måste dock hanteras när det gäller möjlighet till delaktighet och medbestämmande för den äldre personen och närstående i vårdplanering via videomöte. Utan tidigare erfarenhet av videomöten kan kommunikation via en skärm vara en obekant upplevelse. Ett välplanerat videomöte med förberedd och insatt vårdpersonal samt en informerad och trygg patient och närstående är förutsättningar som behöver uppfyllas. / Background: We are becoming older than ever before. A growing number of elderly patients with complex caring needs require coordinated care from a holistic perspective with the patient as a person at the center. A coordinated care planning is conducted in the hospital before discharge in order to coordinate the health care needed from hospital, primary care services and municipal care. Today, these care planning's are often performed via video conference. In order to maintain a person-centered care and provide a safe and secure return to home, care planning need to be carried out in such a way that the elderly person may experience patient participation and thus can influence decisions on their own care and health. Aim: The aim of the study was to describe coordinated care planning via video conference from the elderly person's and next of kin's perspective. Method: An inductive qualitative research approach was used through eight personal unstructured interviews. A purposive sampling was conducted which resulted in a sample of four elderly persons, Md=79 years, (70-83) and four next of kin, Md=54 years, (45-58). Inclusion criteria were experience of care planning via video conference and for the elderly an age of at least 70 years. The data was analyzed with qualitative content analysis. Result: The older person's and the next of kin's experience of care planning via video conference can be described by the theme of being in an alienation. This is derived from three categories based on experience of impersonality, futility and a lack of participation. Insufficient preparation or information may create a feeling of alienation that can hinder the possibility of patient participation, influence and codetermination in the care. Conclusion: Coordinated care planning via video conference may become an adequate meeting form even for the elderly. However, several challenges and difficulties need to be addressed concerning patient participation and codetermination in care planning via video conference. Without previous experience of video conferencing, communicating via a screen can be a strange experience for the elderly person. A well-planned video conference with prepared and trained healthcare personnel as well as an informed and safe patient and next of kin are prerequisites that need to be fulfilled.