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Introduction: Many care organizations have pushed their functional silos to the background, establishing multidisciplinary organizational units to deliver care. Yet, the way these organizational units are designed might produce differences regarding continuity of care, a key performance criterion in chronic care. Consequently, one of the questions we tried to answer in Project CORTEXS is the following: what is the relation between how organizational units are shaped and continuity of care? Theory: Modern Sociotechnical Systems Theory is used to analyze task division and coordination throughout a care process. Task division involves how a composite task (i.e. care delivery) is divided into different tasks and how those tasks are grouped into organizational units: per function, phase or process. Coordination comprises the way task alignment between organizational units takes place, namely centralized (via supervisors or standardization) or decentralized (via direct communication). Continuity of care is conceptualized as the degree of personal follow-up that is provided throughout the care process: none, indirect or direct. Methods: Care process are studied in four specialized Multiple Sclerosis (MS) hospitals in Flanders (Belgium). MS is a highly variable disease, presenting different symptoms and disease courses per patient, which shows the need for continuity of care. The four studied specialized MS hospitals are expected to show variety in task division and coordination. Interviews with representatives of different care disciplines are conducted in each hospital (n=28). Data are investigated using qualitative data analysis techniques. Results: All four hospitals implemented multidisciplinary organizational units. The first hospital installed multidisciplinary departments per function (i.e. acute vs. chronic), but also split them up into work units per function (i.e. professional disciplines), aligning tasks through mixed coordination. No personal follow-up is offered throughout the care process. The second hospital created work units that deliver care throughout a particular phase (i.e. patient episodes) and aligns tasks through mixed coordination, but lacks personal follow-up between phases as well. The third hospital installed work units per phase (i.e. predefined care programs) with mainly centralized coordination. Personal follow-up between phases is missing. The fourth hospital implemented work units that provide care throughout the process (i.e. for a particular patient population), disregarding particular episodes or phases, with a mainly decentralized coordination. Direct personal follow-up is delivered. Conclusions: The urge for multidisciplinary care has been translated into different practices by the four hospitals, which can be related to different degrees of continuity of care. Given the highly individual nature of MS, dividing tasks between aspects and phases that are actually interrelated does not seem to benefit continuity of care. Contrary to the expectations, mixed coordination seems to constrain continuity of care. [ABSTRACT FROM AUTHOR]

Introduction: Background: In many countries, including England, increasing numbers of people survive into old age with multiple chronic health problems. This demographic pattern and financial pressures on health systems have stimulated a twofold substitution of care providers, namely of: 1. Primary for hospital care, where 'primary care' means home nursing services; physiotherapy and other 'allied' health professions; mental health services; and crisis-response services (out-ofhours care, ambulance, outreach etc.) besides general medical practice. Concomitantly, social care is often also required. Even when all these services are present a residual need for secondary care often remains. 2. Informal care (self-care and/or care by spouse, other family members, friends) for formal care. In pursuit of marketisation policies, the UK government is simultaneously attempting to involve voluntary, 'social enterprise' and corporate providers. Problem statement: These changes make it increasingly necessary for someone to actively 'integrate' the care of such patients - more exactly, to co-ordinate the care provided by a range of formal and informal providers so as to promote continuity of care. In theory the GP coordinates a person's health care, but in practice other organisations or individuals sometimes take on this role. That raises the question of how methods and patterns of care coordination differ, when different organisations or individuals fulfil the coordinating role. Theory:Following Donabedian, we assume that health system organisational structures constrain the methods of care integration available to practitioners at local level, and the available methods of care integration constrain what health care outcomes (e.g. continuity of care) are achievable. Methods: Design: Nested case studies tracing the methods and consequences of different care coordination methods from patient level to the organisational context and preconditions at provider level, and from provider to health system level. Sample: Five English localities selected for maximum variety in the types of organisational structures available for integrating patient care. In each locality, a sample (n=68) of patients satisfying a set of clinical criteria for multiple chronic conditions was selected for study. Analysis: 1. Categorisation of care coordination methods and their consequences at patient level, inducted from patient interviews and systematic data extraction from patient medical records 2. Categorisation of organisational factors impeding and assisting care coordination for each type of care coordination method, inducted from (1) and from interviews with healthcare professionals and managers. Results: Provisionally (research continues), we found four main methods of care coordination at patient level: 1. GP as care coordinator (standard English model). GP input was uneven. Liaison and informational continuity with other health services was often problematic, but patients often looked to the GP as care coordinator. Often one or more of the following arrangements coexisted with (1): 2. Other health professions as coordinator, including ad-hoc care coordinating bodies, although these were hard to sustain, and case-management schemes. 3. Patients self-coordinate their care. The more complex their health problems were, the less capable patients often became of coordinating their own care. Patients often under-estimated the severity of their condition and the range of services needed. 4. Third-party integrating organisations, for instance charities such as Age Concern. However, financial pressures made it increasingly hard for health services to support them financially. Conclusions and discussion: These findings derive from small numbers of sites and patients in one country, so great caution is required in generalising empirically from them. They tend to confirm both that the structural separation of general practice from other primary and community care providers compounds the difficulties of care integration; and that it is practically difficult to substitute for the GP's coordinating role for this particular care group. [ABSTRACT FROM AUTHOR]

Introduction: Denmark has highly specialized health care and social service sectors. As a result vulnerable patients, who deal with multifaceted social disadvantaged and chronic and mental illness, often have intersectional pathways involving many different health care and social work staff members. Those patients rarely have resources to manage their own course and without professional coordination, these patients are in danger of not receiving the treatment they need. Consequently there is a need for interdisciplinary and intersectional collaboration to avoid further stigmatization of these patients. Purpose and objective: Professionals experience intersectoral cooperation on vulnerable patients' treatment courses challenging and resource demanding. In addition the professional effort may still not result in continuous pathways. To ensure vulnerable patients access to the health care and social services they need, pathways of vulnerable patients have to be examined. This study wants to identify which processes that lead to consistency in interdisciplinary and intersectoral treatment courses for vulnerable patients. First, this study aims to identify the core components of securing intersectoral pathways of vulnerable patients. Second, based on the findings, the study wants to develop a patient-centred and practice-orientated model that can be used to ensure the patient group coherent intersectoral and interdisciplinary pathways. Third, the study wants to explore the possibilities for digitally support of the model. Methods: The study is designed as a qualitative, explorative case study. The cases are pathways of vulnerable patients from the Centre for Suicide Prevention - Child and Adolescent Psychiatry Odense, Denmark (N=7) and from the Migrant Health Clinic, Department of Infectious Diseases, Odense University Hospital, Denmark (N=7). The empirical data are generated through triangulation and are collected through pathway logs, interviews of professionals and interview of patients. The analysis focuses on identifying themes in the collected data. The themes will be analyzed according to the processes of ensuring the pathways direction, alignment and commitment. Outcome and transferability: This on-going study will present an insight in the actual process of making of integrated care for vulnerable patients in the Region of Southern Denmark. The conference presentation will be centered on the project's methodological findings derived from the data collecting process. The various theoretical methods and approaches are chosen to ensure that the results are relevant to users (patients, health care workers and social work professionals) in clinical practice. By using these approaches it is revealed that the researchers not only gain useful knowledge by scrutinizing the pathways but also experience the challenges of intersectoral pathways themselves while collecting data. This has been an unexpected outcome and adds yet another dimension to project's findings. The project's final results can be used to generate hypotheses in larger scale qualitative and quantitative studies of intersectoral pathways. The procurements will be implemented in the two above mentioned clinics' daily practice and development and in the clinics' conference and training material. The clinical staff will be important partners when implementing the results and passing on the knowledge. Furthermore, a supported integrated care model for vulnerable patients may be transferrable to other patient groups. [ABSTRACT FROM AUTHOR]