Table 2 Findings of what is needed for CoC for people with complex care needs and how to achieve it at different levels of care
Level | What | How | Description |
|---|---|---|---|
Microa Intra-organizational Cooperation | Long-lasting, customized relationships in team-based care | Set aside time to develop - needs-based - holistic relationships | Person-centred care, based on a holistic approach, where unique needs and (personal and environmental) resources determine how care will be designed and planned for the individual |
Provide - predictable and - accessible care with continuous follow-ups | |||
Focus on relational continuity | |||
Mesob Intra- and inter-organizational Cooperation | Dynamic stability in organizational structures and routines for cross-disciplinary teams responsible for geographically defined areas | Establish teams - facilitating long-term patient care - coordination and responsibility | Adaptive and long-term ability of the organizations to handle change and continue to develop in accordance with ever-changing needs (the impression of stability depends on continuous adaptation to changing needs) |
Focus on management continuity | |||
Strive for - low staff turnover - clear professional roles - joint development of routines | |||
Macroc Inter-organizational Cooperation | Long-term solutions that enable knowledge and information exchange and affirm shared responsibility for cohesive care | Support building of lasting inter-organizational cooperation based on - knowledge - trust - respect | Resource allocation enabling joint responsibility for cohesive care and establishment of shared information and communication platforms |
Focus on authorization of informational continuity | |||
Enable - regular cross-organizational information transfer - knowledge exchange |