Sammanfattning
Development of integrated clinical pathways, that include primary care before and after
hospitalisation, was one of the main goals when the government launched the Care Coordination
Reform in Norway in 2012. In the new legislation, hospitals and local health authorities are required
by law to make binding co-operation agreements that coordinate transition of patients both in and out
of hospitals. We have followed some hospitals and adjacent local health authorities that have
collaborated in the development and implementation of clinical pathways that include follow-up in
primary care. We find that specialisation of services and personnel needed for diagnosis specific
pathways was neither sustainable nor functional. Prolonging diagnosis specific pathways into
primary care can also lead to more fragmented services for persons with multiple chronic conditions.
Still, some local health authorities developed a generic (not diagnosis specific) pathway that appears
to be a more sustainable model.