From: Norwegian GPs' participation in multidisciplinary meetings: A register-based study from 2007
1. According to the Patients' Rights Acts municipal health services have the responsibility to set up individual plans (IPs) for "patient who requires long-term, coordinated health service", http://www.ub.uio.no/ujur/ulovdata/lov-19990702-063-eng.pdf) |
2. Municipalities have a coordinating unit responsible for handling initiatives from patients or health-professionals when an IP is wanted and starts the work with the IP for each patient. |
3. A coordinator is appointed in agreement with the patient, normally a person already involved in the treatment or care. GPs are very seldom the coordinator, but are usually included in the process as a medical advisor. |
4. A multidisciplinary team is established, uniquely composed for each IP, based on patient's needs and the services involved. |
5. The coordinator summons the team one to four times a year to plan treatment, rehabilitation and care, and to clarify responsibilities and revise the IP when necessary. |
6. In addition to the patient, and/or close relatives, the participants in the multidisciplinary teams are found among professions obligatory in every Norwegian municipality: Public health nurses Home service nurses Mental health workers Physiotherapists Occupational therapists General practitioners Social workers/children welfare workers Teachers or special teachers |
7. In addition representatives from the specialist health care representatives from the National Insurance Office often participate |