The Linnea Project: realising improvements in the care process between different care-givers for elderly citizens with multiple health problems

PURPOSE: To find out Linnea's (a typical elderly citizen) main problem in her contacts with caregivers and to improve the network between actors around Linnea so that she can feel safe and confident. CONTEXT: Health services for people with multiple health-problems are to a growing extent provided for in the caretakers own home. The responsibility for this care is shared between different authorities and caregivers. A main problem is that each caregiver works from his or her own point of view. DATA SOURCES: 92 interviews with Linnea and different improvements made by multidisciplinary groups form the main data source. CASE DESCRIPTION: Our work was based on the IHI Breakthrough Series methodology, designed to help organisations to rapidly spread improvements. CONCLUSIONS: The main problem for Linnea, among others, is her lack of information and participation and that she would like better access to doctors and nurses. Various small improvements have addressed her different needs and resulted into true improvements for Linnea. The different professions in her network have developed a better mutual understanding for their need to cooperate. DISCUSSION: About 100 participants have learned a new tool for improvements. The future challenge is to keep up the spirit of this network and support spread of new ideas and improvements. The Linnea project continues in 2009 with another 50 multidisciplinary participants.