HOW IT WORKS
The Learning Networks program facilitates patient-centered approaches and improved patient pathways through coordinated care. There is a focus on safe transitions between settings, such as hospitals, primary, or home care. Most patients in the program have complex, chronic conditions and are eligible to participate if they utilize services from health and care providers in the municipality. The initial recommended assessment for patients and their caregivers uses the standardized Patient Specific Functional Scale (PSFS) to define three to five personalized functional activity goals, with results used to develop an integrated health and social care delivery plan to monitor patient progress. Another key feature is the use of a standardized checklists, the Patient Trajectory for Home-Dwelling Adults (PaTH). The focus on patient-defined needs helps drives self-management and empowerment for patients as well as caregivers. It also guides the integrated care team to provide patient-centered care. From patient enrollment to discharge, the program is designed with local health care improvement teams comprising of both health and social care providers.
The program was expanded from one national and one regional network in 2013 to eight networks in the 2016–19 period. A similar approach is currently being developed for individuals with mental illness and drug addiction. The Learning Networks program is being evaluated as part of SELFIE (Sustainable Integrated Care Models for Multi-morbidity: Delivery, Financing and Performance), a Horizon2020 EU project using standardized metrics, quasi-experimental comparisons to control populations, and a common research methodology (multicriteria decision analysis). The Ministry of Health and Care Services initiated a program for the remaining municipalities and hospital regions to participate in learning networks from 2020 to 2022.
Local improvement networks bring together health and social care providers to focus on transitions in care, creating a patient pathway that recognizes the importance of integrated care. This approach instills a shared vision within the multidisciplinary team for coordinating care. The focus on patient-defined goals shifts providers’ perspectives so that they look at patients through a patient-centered, “what matters to you” lens, rather than a “what is the matter with you” lens.
The first recommended step in this program is to use the PSFS to define patient and caregiver needs. As patients transition from hospital to home, each step is guided by clear and consistent patient-centered goals instead of the usual provider-based requirements and milestones. The patient-centered focus not only supports the provision of coordinated health and social care services but also is the basis for patient and caregiver engagement and self-management.
Organizing health care providers into learning networks provides a layer of informal governance that encourages the active participation of local health care providers. Beyond that, the program has a national coordinating group which includes members from the Ministry of Health and Care Services, the Norwegian Association of Local and Regional Authorities (KS), the Norwegian Health Network, and the Norwegian Institute of Public Health.
The program has stable funding and is being actively spread across the country. The Ministry of Health and Care Services provides a small amount of stable funding to support local coordinating offices in each municipality. These offices are responsible for completing assessments and coordinating care for patients in the program.
Additional background: Program website, https://www.fhi.no/kk/forbedringsarbeid/pasientforlop/eldre-og-kronisk-syke/; SELFIE report, https://www.selfie2020.eu/wp-content/uploads/2016/12/SELFIE_WP2_Norway_Final-thick-descriptions.pdf
Additional information on impact: For a summary of research design and methods for the evaluation, see https://bmchealthservres.biomedcentral.com/track/pdf/10.1186/s12913-018-3367-4.