Implementing national care coordination guidelines for people with complex care needs: evidence from a pilot study
Authors: Kalseth Jorid , Kaspersen Silje , Ådnanes Marian , Melby Line 
Published: January 2024

In 2018, The Norwegian Directorate of Health launched an integrated care pilot project aiming to implement national guidelines for a person-centered and coordinated follow-up of people with complex care needs in six municipalities.

Core measures of the pilot are implementing systems for identifying persons in need of interdisciplinary and intersectoral follow-up, implementing structured interdisciplinary follow-up teams as care approach in all services, strengthening the role of care coordinators, and strengthening user involvement and adaption to user needs. The national guidelines are generic and target all services for people with complex needs independent of age and diagnosis. The municipalities participating in the pilot receive financial and process support, and the pilot is monitored closely by the Norwegian Directorate of Health. Initially the pilot was planned to last until 2021 but has been extended until 2023.  Two of the six municipalities did not apply for continuation of the pilot from 2022.

This study report results from a process evaluation of the pilot. The evaluation takes a mixed-methods approach, comprising qualitative interviews and survey data with managers, care coordinators, other municipal employees, as well as service users in the target group. The experiences in putting the national guidelines into practice are discussed based on implementation theory.

The implementation has taken considerably longer time than first planned, and the complexity of the intervention (variety of user groups and services/sectors involved, system change requirements etc.) seems to have been underestimated. The municipalities had different starting points regarding which elements were already in place, which again affected their prioritisations in the first phase of the pilot project. Important implementation barriers were a lack of understanding of the intervention among managers and employees in the municipalities, and ambiguity related to the novelty in the work approaches described in the national guidelines. Furthermore, the COVID-19 pandemic as well as processes of municipal amalgamation in four of the pilot municipalities have drawn attention and resources from the pilot project. Implementation facilitators seems to be having a recognised and dedicated implementation team that knows the organisation well. Strong grounding in all levels of the organisation and having a competent and interdisciplinary coordinating unit in the municipality, with authority to delegate coordination tasks via managers of health and welfare services, is key. A shared understanding and acceptance of the role and responsibility of care coordinators and the follow-up team, within and between sectors, is also important.

To implement new guidelines, structures and work approaches for follow-up of persons with complex care needs constitute a complex intervention that requires thorough preparations and anchoring, understanding and commitment among managers of the services. Employees’ and leaders’ understanding of the usefulness of the intervention and how it differs from existing practice is an important success criterion in the implementation process. While the main focus the first three years has been on getting the necessary structures and systems in place, the emphasis in the last phase of the pilot project is on gaining experiences from structured interdisciplinary follow-up teams as care approach for different user groups.