Integrated Care Pathways in a Community Setting

2014-08-27 03:14:27 | BioPortfolio


The ambition of this study is to raise the quality of care for old and chronically ill patients by establishing a sustainable, systematic prevention and integrated care model for users of home care services.


The primary objective of this study is to develop a functional and integrated care model between primary and secondary health care that will meet the needs both in the city and in smaller rural areas.

The secondary objective of this study is to reduce the need of care at primary and secondary level through a a systematic and integrated follow-up by home care nurses and GPs to:

- Enable these patients to manage their health needs more efficiently and independently

- Achieve better collaboration within primary care

- Achieve better collaboration between primary- and secondary health care professionals

- Achieve increased satisfaction and confidence with the health care services by the users and their relatives both for included patients and other patients receiving home care services.

- Promote health and prevent unnecessary decline in health

- Strengthen the patients' ability to manage their daily activities.

Study Design

Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Health Services Research


Frail Elderly


Systematic integrated care model


Fræna Municpality




Norwegian University of Science and Technology

Results (where available)

View Results


Published on BioPortfolio: 2014-08-27T03:14:27-0400

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