In Norway, as in most Western societies, health authorities consider health and social services to be fragmented; especially challenging is a lack of continuity of care for elderly and chronically ill patients [1–4]. More outpatient care, fewer hospital beds and shorter inpatient stays redirect more rehabilitation and follow-up to primary care at an increasingly earlier stage of treatment [2, 5]. Studies show that there is a considerable risk of adverse events in relation to the transition of patients between hospitals and primary care services and that information provided is often insufficient [6–8]. Thus, there is a growing need for better care coordination between primary and specialist health care services to ensure patient safety and continuity of care [1, 9].
Many countries have focused attention on improving the coordination of their health and social care services [10, 11]. In some European countries, models for hospital-at-home regimens have been developed as a beneficial alternative to inpatient care for selected patients [12, 13]. Treatment and follow-up takes place in the patient’s home, with an ambulatory team from the local general hospital remaining responsible for patient care. Other models describe care pathways that aim to ensure adequate follow-up after discharge, involving both specialist and primary care services [14, 15]. Most studies in the field evaluate models that have been initiated by specialist care services and are based on treatment of single diseases like stroke, heart failure and COPD [16–18]. Some studies describe care pathways for hospitalized elders more generally . In these studies, hospital-based practice nurses or multidisciplinary teams are usually involved in the discharge process and for a limited post-discharge period. In Denmark an intervention was developed within primary care by GPs and home care services that reduced the risk of readmissions and improved medication control for newly discharged elderly patients .
Models have also been developed to improve the follow-up care of patients with chronic conditions in primary care. The Chronic Care Model has been introduced at several sites but targets mostly single diseases [21, 22]. More recently, the Patient-Centered Medical Home model has been launched in the US .
Cultural differences between specialist care and primary care are not unknown . However, we have not found studies investigating the potential implications that the different professional cultures might have on the process of developing care pathways across care levels.
In Central Norway a primary-care initiated project was set up where the main objective was better care coordination and follow-up during and following discharge from hospital to home by developing integrated care pathways. Being a cluster-randomised complex intervention, a process evaluation nested inside the trial was started in order to clarify causal mechanisms and to identify obstacles or other contextual factors contributing to the variation, success, or failure of the interventions . The aim of this paper was to explore the process of developing the integrated care pathways that was going to be implemented in the project.