Table 1
Characteristics of informants (n = 21).
| GROUP | |||||||
|---|---|---|---|---|---|---|---|
| 1 n = 2 | 2 n = 5 | 3 n = 2 | 4 n = 4 | 5 n = 4 | 6 n = 2 | 7 n = 2 | |
| Profession | |||||||
| General practitioner | 2 | 1 | |||||
| Nurse (General Practice) | 1 | ||||||
| Chief Physician (Pulmonary Dept.) | 1 | ||||||
| Head Nurse (Pulmonary Dept.) | 1 | ||||||
| Physician (Pulmonary Dept.) | 3 | ||||||
| Nurse (Pulmonary Dept.) | 2 | ||||||
| Manager (Healthcare Centre) | 2 | ||||||
| Nurse (Healthcare Centre) | 2 | 2 | |||||
| Physiotherapist (Healthcare Centre) | 2 | 2 | |||||
Table 2
Barriers and facilitators to integrating care.
| Area | Barriers | Facilitators/solutions |
|---|---|---|
| Communication/information transfer | ||
| Information technology systems | No integrated information system to facilitate transfer of information across settings | An electronic system accessible across settings making it possible to search for relevant patient information like referrals, discharge letters, test results and short annual resumes about patients and their treatment |
| The diagnostic phase | Inadequate referrals due to lack of information about the medical regimen, smoking status and old or missing test results | Improve quality of care in general practice through a focus on early detection and interpretation of test results |
| Clear referral procedures | ||
| Knowledge-sharing meetings with representatives from each setting discussing a sample of patient cases to address incentives, barriers, strengths and weaknesses and opportunities to provide high-quality and well-integrated patient pathways | ||
| The phase between regular visits at the outpatient clinic for the very severe patients | No opportunities for patients and general practitioners to get advice or help between regular visits at the outpatient clinic | A 24-hour nurse-led chronic obstructive pulmonary disease-specific hotline service at the hospital available for both patients and general practitioners |
| A case manager with specific training and expertise in caring for patients with chronic obstructive pulmonary disease, who contacts patients directly to ensure that they attend appointments and adhere to their medications. In addition the case manager would facilitate access to care services in other departments of the hospital and in the municipality and coordinate aspects of social care services, such as home care | ||
| The hospital discharge phase | Discharge letters from the hospital are often inadequate due to lack of information about changes in the medication regimen and a missing rationale for the changes | Clear discharge procedures and a higher priority to producing discharge letters in the hospital |
| Discharge letters also miss an adequate description of the future care plan, including the patients’ goals and preferences | Knowledge-sharing meetings with representatives from each setting discussing a sample of patient cases to address incentives, barriers, strengths and weaknesses and opportunities to provide high-quality and well-integrated patient pathways | |
| Committed leadership | Leaders who are not committed and do not communicate clearly about the importance of integrated care | Managers consistently sharing a vision of integration with their employees |
| Front line staff unwilling to take responsibility | Managers acknowledging tasks related to interorganisational integration and prioritising and allocating time for completing them | |
| Informal network meetings between managers from each setting | ||
| Patient engagement | Professionals planning and communicating in a triangle around the patient | Shared decision-making |
| The use of patients’ own resources | ||
| Patient activation and responsibility | ||
| The role and competencies of general practitioners | At the healthcare centres and the hospital, managers and clinicians received a remarkably small number of referrals from general practice; very often inadequate because of missing information or dated test results | Improve quality of care in general practice; focus on early detection and interpretation of test results |
| Clear referral procedures | ||
| Clinical guidelines with clear directions on the management of comorbidities | ||
| Knowledge-sharing meetings with representatives from each setting discussing a sample of patient cases to address incentives, barriers, strengths and weaknesses and opportunities to provide high-quality and well-integrated patient pathways | ||
| Organisational culture | Differing perspectives, cultures and working conditions in different sectors created a great need for understanding the concerns and needs of others | Knowledge-sharing meetings with representatives from each setting discussing a sample of patient cases to address incentives, barriers, strengths and weaknesses and opportunities to provide high-quality and well-integrated patient pathways |
| Spending time at others’ work places |