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Scenario for a patient at home in health and social care
Stockholm University, Faculty of Social Sciences, Department of Computer and Systems Sciences.
2014 (English)In: Journal of Healthcare Leadership, ISSN 1179-3201, E-ISSN 1179-3201, no 6, 51-66 p.Article in journal (Refereed) Published
Abstract [en]

This paper describes and discusses the situation for a typical patient with multiple illnesses and how his case would benefit from improved coordination, communication, and collaboration among all involved care providers. The paper is built around a patient case presented in a current scenario. The authors identified that for a single patient with several problems and diagnoses and the involvement of several care actors, the common issues concern lack of collaboration, lack of coordination, and awareness of what others have done to assess, plan, perform, and evaluate care. This presumably leads to a lack of care quality and a lack of effective use of care resources. The scenario and the findings are based on a patient-oriented perspective, on an analysis expressed in focus groups, and on interviews with key actors in health and social care. The paper also discusses the fact that an increasing number of patients are treated in their homes by a variety of organizations, and how this fact raises new and more intense demands on the various stakeholders forming the care staff to collaborate and coordinate care. We point to the need for managers in and between organizations to agree on the ways of collaborating at the operational level. Most importantly, by taking a basic set of issues as the starting point for reasoning, we derived a set of related problems and suggest solutions to deal with these. The literature currently lacks scenario descriptions that put the patient's situation into focus with respect to collaboration between health and social care. Finally, the paper presents a future case for collaboration including support by new e-services.

Place, publisher, year, edition, pages
2014. no 6, 51-66 p.
Keyword [en]
multisectorial collaboration, coordination, communication, patient-centered care, home care, health and social care
National Category
Information Systems Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Computer and Systems Sciences
URN: urn:nbn:se:su:diva-132870DOI: 10.2147/JHL.S68167OAI: diva2:955428
Available from: 2016-08-25 Created: 2016-08-25 Last updated: 2016-08-25Bibliographically approved
In thesis
1. Collaboration and Coordination Challenges in Patient-Centered Care: Models and Informaion Services
Open this publication in new window or tab >>Collaboration and Coordination Challenges in Patient-Centered Care: Models and Informaion Services
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This thesis reports on research focuses on how to deal with the fact that the organization and processesof today’s health and social care are becoming ever more complex as a consequence of societal trends, including an aging population and an increased reliance on care at home. The overall research goal is to suggest ways in which IT-based solutions can enable and leverage collaboration and coordination insituations where a co-morbid patient is subject to care delivered simultaneously by several different professionals and organizations.

Patient-centered care is defined as quality health and social care achieved through a partnership between informed and respected patients, their families, and coordinated health and social care teams who conduct care activities according to jointly determined care plans.

Against a background of several years of research on patient-centered collaborative care using adesign science approach, using techniques such as focus groups, interviews, and document studies, the author of the thesis has further pursued the work in a project named CoCare. Results show that the care required in aging societies is both a social and a technical challenge. Meeting this challenge will require a redesign of today's health and social care processes in order to focus more clearly on patient needs and values, and poses demands on information services allowing to share knowledge of the patient’s health and social situation among involved care providers. An important aspect of the increased complexity is that a single patient may need care from several autonomous care providers in parallel, particularly patients with co-morbidities. This clearly requires effective coordination of care activities, which poses further demands on information services to support this task.

A set of issues involving patient-centered collaborative care is identified and analyzed. The thesis introduces the notions of the Patient-Centered Care Process (PCCP) and a conglomeration of suchprocesses. A conglomeration comprises a set of PCCPs that concern the same patient, that are overlapping in time, and that share the overall goal of improving and maintaining the health and socialwell-being of the patient. The PCCP is inspired by the well-known PDCA cycle and comprises the four phases of assessing the patient situation (ASSESS), planning care activities (PLAN), performingcare activities (DO) and following up care (CHECK) for the patient. Based on a number of key standards, such as HL7, HISA and CONTsys, the thesis introduces a Patient-Centered Information Model (PCIM). A set of information services, together constituting a Coordination Hub, is proposed. The information services aim to help formal as well as informal carers (including the patient) inconducting care according to the PCCP

The thesis contributes to a deeper understanding of care processes and suggests ways to achieve patient-centered collaborative care that better contributes to creating value for the patient as an individual.

Place, publisher, year, edition, pages
Stockholm: Department of Computer and Systems Sciences, Stockholm University, 2016. 141 p.
Report Series / Department of Computer & Systems Sciences, ISSN 1101-8526 ; 16:010
patient-centered care, healthcare, social care, home care, collaboration, coordination, care processes, processes coordination, multi-sectoral collaboration, communication, information models, information services, management
National Category
Computer and Information Science
Research subject
Computer and Systems Sciences
urn:nbn:se:su:diva-132693 (URN)978-91-7649-471-4 (ISBN)
External cooperation:
Public defence
2016-10-07, Lilla hörsalen, NOD-huset, Borgarfjordsgatan 12, Kista, 14:00 (Swedish)
Available from: 2016-09-14 Created: 2016-08-18 Last updated: 2016-09-05Bibliographically approved

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