| Summary: | Background: People often experience failure in communication and lack of coordination leading to worsening of illness, and frustration treated in several healthcare-sectors. It also often leads to increased use of healthcare- resources. Increased specialisation and different management-paradigms have somehow changed focus from the general care and the need of those who need it the most. At NSR Hospital, the readmission rate for acute somatic admissions is among the highest in Denmark. From Slagelse Municipality, the readmission rate is very high too. In Slagelse the municipality, general practice and both the psychiatric and the somatic hospital have high ambitions for the locale cross-sectorial-collaboration and want to establish collaborations, which provide patients with good experiences. The project ”Cross-sectorial whiteboard-meeting” was establish after an analysis of the challenges in the cross-sectorial-collaboration. Therefore, a meeting every two weeks between Slagelse Municipality, General Practice and NSR Hospital was trialed. There was special focus on readmission within five days. Hypothesis: We expected that the systematic analysis and the following testing of workflow in the cross-sectorial-collaboration would reduce readmission and secure good cross-sectorial patient-trajectories with equally high quality with the person in the center and with the right use of resources in the right sector. Method and design: We used Improvement Science. Data was up-to-date, and Plan-Do-Study-Act-circles were used to change the workflow. The model: What do we wish to achieve? When do we know that a change is an improvement? Which changes do we want to try? Testing of changes: The chosen changes suggested at the whiteboard-meetings were a continuous development of the cross-sectorial-collaborations. Implement changes: We implemented the changes, which showed good effect in existing workflow to benefit for all admitted patients. Assessment: Interview with health-professionals evaluating the outcome of their work with people often admitted to hospital. Results: The team: Participants in the whiteboard-meeting must be relevant for the problems. The participants were : From NSR Hospital: two deputy directors, five leading head-nurses, 1 leading therapist and four from the administration. From the municipality: Health-director, health-development-consultant, health-coordinator, head of visitation, acute-team-leader and a consultant for psychiatry and handicap. From the psychiatry in the Region: two head-nurses and one head consultant. One General Practice consultant. Citations from participants in the cross-sectorial whiteboard-meeting: Municipality-leader ”The meeting makes so much sense. I tell my colleagues that in the hospital they work seriously with preparing the discharge. It means a lot to follow the initiatives taken to improve the discharge-process. It makes my colleagues optimize their part of the collaborative–process”. Hospital-case-manager ”The meetings are an opportunity to exchange necessary views on the discharge-process. It is very valuable to hear what the municipality finds we can improve on. We exchange views and get an understanding of each other’s’ challenges.” Hospital-leader ”These meetings are more than just meetings where we orientate each other of problems with the transitions between sectors and readmissions, Here we focus on learning from the action. It is meaning-creating and contributes to improvement. It rocks”. At the conference, we will elaborate on the study-outcome.
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