Collaboration and Coordination Challenges in Patient-Centered Care : Models and Informaion Services

Abstract: This thesis reports on research focuses on how to deal with the fact that the organization and processesof today’s health and social care are becoming ever more complex as a consequence of societal trends, including an aging population and an increased reliance on care at home. The overall research goal is to suggest ways in which IT-based solutions can enable and leverage collaboration and coordination insituations where a co-morbid patient is subject to care delivered simultaneously by several different professionals and organizations.Patient-centered care is defined as quality health and social care achieved through a partnership between informed and respected patients, their families, and coordinated health and social care teams who conduct care activities according to jointly determined care plans.Against a background of several years of research on patient-centered collaborative care using adesign science approach, using techniques such as focus groups, interviews, and document studies, the author of the thesis has further pursued the work in a project named CoCare. Results show that the care required in aging societies is both a social and a technical challenge. Meeting this challenge will require a redesign of today's health and social care processes in order to focus more clearly on patient needs and values, and poses demands on information services allowing to share knowledge of the patient’s health and social situation among involved care providers. An important aspect of the increased complexity is that a single patient may need care from several autonomous care providers in parallel, particularly patients with co-morbidities. This clearly requires effective coordination of care activities, which poses further demands on information services to support this task.A set of issues involving patient-centered collaborative care is identified and analyzed. The thesis introduces the notions of the Patient-Centered Care Process (PCCP) and a conglomeration of suchprocesses. A conglomeration comprises a set of PCCPs that concern the same patient, that are overlapping in time, and that share the overall goal of improving and maintaining the health and socialwell-being of the patient. The PCCP is inspired by the well-known PDCA cycle and comprises the four phases of assessing the patient situation (ASSESS), planning care activities (PLAN), performingcare activities (DO) and following up care (CHECK) for the patient. Based on a number of key standards, such as HL7, HISA and CONTsys, the thesis introduces a Patient-Centered Information Model (PCIM). A set of information services, together constituting a Coordination Hub, is proposed. The information services aim to help formal as well as informal carers (including the patient) inconducting care according to the PCCPThe thesis contributes to a deeper understanding of care processes and suggests ways to achieve patient-centered collaborative care that better contributes to creating value for the patient as an individual.