About the project
The rehabilitation process for those persons suffering from serious illness or injury commences in the hospital and care transfers to the team within their own municipality. Historically services to this client group within the community have been compromised by; competency of staff and capacity levels within the community, poor exchange of information including clinical handover, care plans and client goals, and little use of common communication tools.
A new inter-professional and inter-municipality team (IKART) has been established in the Sør-Rogaland region to offer the municipalities professional guidance and assistance in the transition process and commencement of rehabilitation for this patient group. IKART actively participates in the planning, implementation and specific treatment of the individual patient. IKART also provides professional guidance to the locally based professionals. An essential element in this process is to assist with the implementation of the communication tools to ensure that information and coordination of care is accurate and timely between all parties. After one year in service, IKART has received positive feedback from both collaborators and patients.
The aim of this study is to further examine the methods and tools used for adopting a seamless transition of care. There will be a particular focus on technological tools and how these affect the patient pathways, transition and experience. Methods will be to observe the rehabilitation pathways, focus group interview with healthcare workers, and individual interview with patients.
Master of Evidence-based Practice in the Health Sciences, Bergen University College 2009-2012