Figure 1
PORT prototype.
Table 1
Data and participants.
| TYPES OF DATA | PARTICIPANTS (N) |
|---|---|
| Formal start-up meetings (Field notes) | Geriatric and Palliative Department, Bispebjerg and Frederiksberg Hospital Joint Specialty Clinic, Bispebjerg and Frederiksberg Hospital Emergency Department, Bispebjerg and Frederiksberg Hospital Municipality of Copenhagen Municipality of Frederiksberg General practitioners |
| Individual interviews (Transcriptions and field notes) | Patients with multimorbidity (12) |
| Workshops within each sector (Transcriptions and field notes) | 1.Nurses from with the Geriatric and Palliative Department, Bispebjerg and Frederiksberg Hospital (3) 2.Managers, doctors, nurses, and secretaries from the Joint Specialty Clinic, Bispebjerg and Frederiksberg Hospital (4) 3.Nurses from the Emergency Department, Bispebjerg and Frederiksberg Hospital (2) 4.The municipality of Copenhagen (2) 5.The municipality of Frederiksberg (6) 6.General practitioners in the local area of Frederiksberg Municipality (5) 7.General practitioners in the local area of Copenhagen Municipality (3) + one individual interview |
| Ad hoc intervention development group meetings (Field notes) | Steering group meeting 1 – GP – JSC management – JCS nurses – Copenhagen Municipality – Frederiksberg municipality – Steering group meeting 2 – Frederiksberg municipality – JSC – GP – Steering group meeting 3 |
| Meetings with steering group (Transcriptions and field notes) | Members of the steering group (8) |
Table 2
Identified areas which impact integration of care.
| PATIENTS | HOSPITAL | MUNICIPALITY | GENERAL PRACTICE | EVIDENCE | |
|---|---|---|---|---|---|
| Information sharing | Repeatedly new contacts without knowledge | Lacking information and contact information | Lacking information and contact information | Lacking information and contact information | General overview challenging for all parties |
| Decisions across sectors | Lacking follow-up and contact | Wish for shared decision making | Unclear responsibilities, different views on needs | Unclear responsibilities, wish for shared decision making | Multiple barriers for global decisions |
| Healthcare fragmentation | Uncertainty about healthcare responsibility | Initiate compensatory interventions | Find coordination tasks challenging | Embrace gate-keeper role but not care coordination | Implementation challenges in primary care |
| Patient centeredness | Wish for information and a personal relationship with healthcare providers | Challenging to assess supportive needs | Embrace supportive role but is impaired by lacking information | Challenging to assess supportive needs | Treatment burden in addition to disease burden |