Samverkan vid vårdplanering för patienter med komplexa behov – ett mellanorganisatoriskt triangeldrama

Sammanfattning: Aims: The overall aim of this thesis was to deepen the knowledge of collaboration in care planning across healthcare provider boundaries for patients with complex care needs. Specific aims were: to highlight specialist nurses´ experiences of coordinated care planning in primary care (I); to investigate care center manager ´s understanding of the ability of primary care to provide coordinated care planning for patients with complex needs (II); to focus on health professionals from different organizations and describe their experiences of obstacles and opportunities for collaboration with patients and their relatives and between caregivers for frail elderly patients with multiple diseases (III); to investigate inter-organisational collaboration on care efforts for patients with complex care needs (IV). Methods: In study I and III, focus groups were used as a data collection method and analyzed with inductive qualitative content analysis. In study II, individual interviews were conducted and analyzed with deductive qualitative content analysis. In study IV, a survey was used for a total population of health managers in hospitals, health centers and medically responsible nurses (MAS) in Sweden. Data were analyzed with descriptive statistics, bivariate and multivariate regressions. Results: The result highlights the importance of creating consensus in relation to patients and responsible healthcare providers (I). Collaboration in care planning between primary care and other healthcare providers is dominated by non-cooperation (II). Communication with patients and related parties is insufficient and delayed between care providers. There is a lack of adequate care planning and the resources are not distributed according to patients´ needs (III). Each health care organization values its own ability to interact more than they value each other. Primary care and municipality attribute to each other a smoother collaboration than they attribute to hospitals, but primary care is judged to have the least accessibility, lowest degree of willingness to care and trustworthiness of the three organisations in care planning for patients with complex care needs (IV). Conclusions: The communication skills of specialist nurses are of utmost importance for involving and supporting patients and related parties in the care process and for achieving consensus among healthcare providers in the decisions made during care planning. The healthcare manager´s knowledge of primary care´s participation, role and responsibility in care planning was permeated by uncertainty about the tasks. The healthcare staff emphasizes obstacles to collaboration in healthcare planning at social, organisational and individual level. With improved systems for communication, joint care plan and regulated overall responsibility for patients throughout the care process, the possibilities for collaboration increase. Health managers and MAS judge that there is an inability to inter-organisational collaboration, which to some extent can be explained by a discrepancy between one´s own and others´ perception of accessibility, service willingness, trustworthiness and collaboration between hospital, municipality and primary care.