Morsø Lars, Hansen Michael Skriver, Brink Anette, Thams Mette, Thude Bettina Ravnborg
Open Patient data Explorative Network (OPEN), Region of Southern Denmark, DK.
Department of Clinical Research, University of Southern Denmark, Odense, DK.
Int J Integr Care. 2021 Mar 2;21(1):10. doi: 10.5334/ijic.5503.
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.
To ensure referral to municipality COPD rehabilitation, by simplifying the referral procedures, and by facilitating relational coordination across the two health care settings.
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.
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.
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.
慢性阻塞性肺疾病（COPD）患者能从康复计划中极大获益，但转介至康复治疗的情况却很罕见。在我们开展活动以确保在市政层面为预防计划进行医院转介之前，我们调查了跨部门工作流程中的转介模式及相关因素。
通过简化转介程序，并促进两个医疗环境之间的关系协调，以确保转介至市政COPD康复治疗。
我们通过使所有转介包含标准措辞、全部发送至同一电子位置，并确保所有患者都被转介至同一次初始面谈，来简化转介程序。我们通过建立本地和跨部门网络小组来促进跨部门关系协调。我们对网络小组进行监测，并发送问卷以了解网络活动情况。我们使用指标来衡量跨部门质量，并用问卷来衡量患者体验到的质量。
我们发现转介系统存在缺陷，这意味着一些转介被忽视了。基于所掌握的知识和经验，各网络要求进行调整。这导致了患者纳入和数据收集方面的调整。
我们成功简化了转介程序，并促进了跨部门关系协调。我们必须对程序、信息、内容、人群和数据基础设施不断进行调整。在简化转介程序并促进跨部门关系协调方面。我们必须对程序、信息、内容、人群和数据基础设施不断进行调整。
