How to Ensure Referral and Uptake for COPD Rehabilitation—Part 1: Disentangling Factors in the Cross-Sectorial Workflow of Patients with COPD to Understand why Most Patients are not Referred to Rehabilitation

INTRODUCTION: Chronic obstructive lung disease (COPD) is one of the most serious and common chronic conditions. Patients having COPD can greatly benefit from rehabilitation initiatives. However, not all patients having COPD are referred to rehabilitation. Literature does not clearly explain why only some patients with COPD are referred to rehabilitation, and only very few successful solutions to address the complexity of cross-sectorial organisations are described. The overall objective of this research project is to ensure referral and uptake for COPD rehabilitation. We focus on detangling the processes in the cross-sectorial workflow of patients with COPD to understand why most patients are not referred to rehabilitation. METHODS: Based on semi structured interviews and observations a FRAM analysis was conducted to map the referring routines from hospital to municipality. RESULTS: We found that the hospital and the municipality have different understandings of what rehabilitation is, they use different words and hospital staff lack knowledge of offers at the municipality. CONCLUSION: The FRAM analysis was useful to detangle factors important to cross-sectorial collaboration and resulted in a series of focus areas that were disseminated at a workshop. The municipality and the hospital agreed to initiate activities to develop and coordinate the cross-sectorial relations.