Integrated care for chronic conditions: a multi-method controlled evaluation

The Central Norway Regional Health Authority (Helse Midt-Norge RHF) is to develop a structured collaboration between community and specialist care for people with chronic conditions. As an important part of this the patients will be mobilised by training and education to become more independent and self-reliant. The new integrated care will be based on the ordinary healthcare systems in the municipalities (coordination unit, general practitioner, home based care and nursing homes). The main contribution from the specialist health care is transfer of competence, tutoring and to operationalize evidenced based medical guidelines into local clinical pathways. Individual care plans will be used when suitable for the purpose. Monitoring and electronic commun ication will be facilitated by establishing a call centre. The central will be a useful tool to coordinate specified actions to the patients, in cooperation with the health care services, patients, their relatives and organizations. The main purpose of t his protocol is to design a research based evaluation of the project, using both quantitative and qualitative methods. Indicators of admissions and re-admissions at general hospital, use of nursing homes and home care support, and patients level of functi on and quality of life will be important quantitative measures. The qualitative study will evaluate the patients? and their relatives satisfaction on the integrated care model, organisational effects and the communication and collaboration between the dif ferent levels in the health care services. This is the first time a model with a call centre especially designed for the care of chronic patients is tried out and evaluated in Norway. If the integrated care model shows a significant positive effect, the m odel should be incorporated as an alternative to the acute care model for patients with defined types of chronic conditions.