Kneck Åsa, Flink Maria, Frykholm Oscar, Kirsebom Marie, Ekstedt Mirjam
Ersta Sköndal Bräcke University College, Department of Health Care Sciences, Stockholm, SE.
Division of Family medicine and Primary care, NVS, Karolinska Institutet, SE.
Int J Integr Care. 2019 Sep 26;19(3):20. doi: 10.5334/ijic.4192.
Integrated care is believed to provide support to patients with multiple long-term and complex conditions. Transparency in information delivery is key for shared decision-making, and co-production of care. This study aimed to explore information pathways within an integrated healthcare and social care organisation and describe how information continuity was delivered for an older patient with complex care needs.
An explorative single-case study conducted in a Swedish healthcare organization where municipality and the county council have integrated their services. One focus group discussion and six individual interviews were conducted.
Information flow to partners in care was obstructed, with compensatory double documentation, complementary information channels, and information loss. A heavy burden was on the patient and relatives to keep track of and communicate information between different caregivers. Patients were expected to be active partners in their own care, but were largely excluded from the information flow.
Even integration of care organisations does not imply that integrated care is delivered at the sharp end of practice. An integrated electronic health record is needed to improve accessibility of care information from within all the organisations, facilitating handovers between professionals and levels of care, and involving patients in the information flow.
综合护理被认为能为患有多种长期复杂病症的患者提供支持。信息传递的透明度是共同决策和护理共同生产的关键。本研究旨在探索综合医疗保健和社会护理组织内的信息路径，并描述如何为有复杂护理需求的老年患者提供信息连续性。
在瑞典一个市政当局和郡议会已整合服务的医疗保健组织中进行了一项探索性单案例研究。进行了一次焦点小组讨论和六次个人访谈。
向护理伙伴的信息流受阻，存在补偿性双重记录、补充信息渠道和信息丢失的情况。患者及其亲属要在不同护理人员之间跟踪和传达信息，负担很重。患者被期望成为自身护理的积极伙伴，但在很大程度上被排除在信息流之外。
即使护理组织实现了整合，也并不意味着在实际操作的关键环节就能提供综合护理。需要一个综合电子健康记录来提高所有组织内部护理信息的可及性，促进专业人员之间和护理层面之间的交接，并让患者参与信息流。
