How to Ensure Referral and Uptake for COPD Rehabilitation-Part 1: Disentangling Factors in the Cross-Sectorial Workflow of Patients with COPD to Understand why Most Patients are not Referred to Rehabilitation.

INTRODUCTION: Chronic obstructive lung disease (COPD) is one of the most serious and common chronic conditions. Patients having COPD can greatly benefit from rehabilitation initiatives. However, not all patients having COPD are referred to rehabilitation. Literature does not clearly explain why only some patients with COPD are referred to rehabilitation, and only very few successful solutions to address the complexity of cross-sectorial organisations are described. The overall objective of this research project is to ensure referral and uptake for COPD rehabilitation. We focus on detangling the processes in the cross-sectorial workflow of patients with COPD to understand why most patients are not referred to rehabilitation. METHODS: Based on semi structured interviews and observations a FRAM analysis was conducted to map the referring routines from hospital to municipality. RESULTS: We found that the hospital and the municipality have different understandings of what rehabilitation is, they use different words and hospital staff lack knowledge of offers at the municipality. CONCLUSION: The FRAM analysis was useful to detangle factors important to cross-sectorial collaboration and resulted in a series of focus areas that were disseminated at a workshop. The municipality and the hospital agreed to initiate activities to develop and coordinate the cross-sectorial relations.

How to Ensure Referral and Uptake for COPD Rehabilitation - Part 2: A Case of Integrated Care on How to Translate Findings of Cross-Sectorial Workflow to Improve Cross-Sectorial Rehabilitation.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) can greatly benefit from rehabilitation initiatives, but referral to rehabilitation is sparse. Before we initiated activities to ensure hospital referrals for prevention initiatives at the municipality, we investigated referral patterns and relevant factors in the cross-sectorial workflow. OBJECTIVE: To ensure referral to municipality COPD rehabilitation, by simplifying the referral procedures, and by facilitating relational coordination across the two health care settings. METHODS: We simplified the referral procedure by initiating all referrals to contain standard wording, all send to the same electronic location, and assuring that all patients were referred to the same initial interview. We facilitated cross-sectorial relational coordination by establishing local- and cross-sectional network groups. We monitored the network groups, and send questionnaires to obtain knowledge of network activities. We used indicators to measure the cross-sectorial quality and questionnaires to measure the patient experienced quality. RESULTS: We detected flaws in the referral system that meant that several referrals were neglected. Based on knowledge and experiences the networks called for adjustments. This led to adjustments in patient inclusion and data collection. CONCLUSION: We succeeded in simplifying referral procedures and facilitated cross-sectorial relational coordination. We had to make ongoing adjustments of procedures, information, content, population and data infrastructure.in simplifying referral procedures and facilitated cross-sectorial relational coordination. We had to make ongoing adjustments of procedures, information, content, population and data infrastructure.