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Table 1 Overview of selected community projects

From: Care pathways across the primary-hospital care continuum: using the multi-level framework in explaining care coordination

Case Region Focus Patients / year Start Composition multidisciplinary group Core staff
1 1 Patients treated with a prostatectomy from first appointment with specialist till post-surgical control 200 2005 Representatives of hospital (n = 6) and all primary care services involved (n = 18) Staff members of hospital, home care service and SELa, all members of core staff changed during project
2 2 Patients referred to specialist for prostatectomy till follow-up 250 2005 Representatives of hospital (n = 1) and primary care (n = 5) Staff of a home care service
3 2 Initial period “follow-up for patients with breast cancer” changed into “from referral till second post-op consultation” 200 2002 Specialists (n = 3), general practitioners (n = 3) and a specialized nurse since September 2008 1. Staff member of hospital and researcher;
2. General practitioner and specialist
4 3b Surgical breast care patient from discharge from hospital till start of after treatment 160 2006 Representatives of hospital (n = 9) and primary care, including patient representatives (n = 16) 1. Staff member of hospital and SELa; 2. Specialist, general practitioner and staff member of hospital
5 4b Surgical breast care patient from discharge from hospital till start of after treatment 200 2006 Representatives of hospital (n = 10) and primary care including patient representatives (n = 16) Staff member of hospital and SELa
  1. aSEL provides a platform of consultation to assist and extend home care, beyond the boundaries of the own organization, office or discipline.
  2. bCare pathways in these cases were developed in cooperation with different hospitals but with partially overlapping primary care.
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