How to Ensure Referral and Uptake for COPD Rehabilitation – Part 2: A Case of Integrated Care on How to Translate Findings of Cross- Sectorial Workflow to Improve Cross-Sectorial Rehabilitation

Background: Patients with chronic obstructive pulmonary disease (COPD) can greatly benefit from rehabilitation initiatives, but referral to rehabilitation is sparse. Before we initiated activities to ensure hospital referrals for prevention initiatives at the municipality, we investigated referral patterns and relevant factors in the cross-sectorial workflow. Objective: To ensure referral to municipality COPD rehabilitation, by simplifying the referral procedures, and by facilitating relational coordination across the two health care settings. Methods: We simplified the referral procedure by initiating all referrals to contain standard wording, all send to the same electronic location, and assuring that all patients were referred to the same initial interview. We facilitated cross-sectorial relational coordination by establishing local- and cross-sectional network groups. We monitored the network groups, and send questionnaires to obtain knowledge of network activities. We used indicators to measure the cross-sectorial quality and questionnaires to measure the patient experienced quality. Results: We detected flaws in the referral system that meant that several referrals were neglected. Based on knowledge and experiences the networks called for adjustments. This led to adjustments in patient inclusion and data collection. Conclusion: We succeeded in simplifying referral procedures and facilitated cross-sectorial relational coordination. We had to make ongoing adjustments of procedures, information, content, population and data infrastructure.in simplifying referral procedures and facilitated cross-sectorial relational coordination. We had to make ongoing adjustments of procedures, information, content, population and data infrastructure.