Thude Bettina Ravnborg, Brink Anette, Hansen Michael Skriver, Morsø Lars
Department of Medicine, Hospital Sønderjylland, Sønderborg, DK.
Health Department, Municipality of Sønderborg, Sønderborg, DK.
Int J Integr Care. 2021 Mar 2;21(1):9. doi: 10.5334/ijic.5502.
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.
Based on semi structured interviews and observations a FRAM analysis was conducted to map the referring routines from hospital to municipality.
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.
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.
慢性阻塞性肺疾病（COPD）是最严重且常见的慢性疾病之一。患有COPD的患者能从康复计划中极大受益。然而，并非所有COPD患者都被转介至康复治疗。文献并未清晰解释为何仅有部分COPD患者被转介至康复治疗，且针对跨部门组织复杂性的成功解决方案描述极少。本研究项目的总体目标是确保COPD康复治疗的转介与接受。我们专注于理清COPD患者跨部门工作流程中的各个环节，以理解为何大多数患者未被转介至康复治疗。
基于半结构化访谈与观察，进行了FRAM分析，以梳理从医院到市政当局的转介流程。
我们发现医院和市政当局对康复治疗的理解不同，使用的措辞各异，且医院工作人员对市政当局提供的服务缺乏了解。
FRAM分析有助于理清跨部门合作的重要因素，并产生了一系列在研讨会上公布的重点领域。市政当局和医院同意开展活动，以发展和协调跨部门关系。
