Table 5

Observed challenges in the delivery of integrated patient care

Observed challenge in integration of servicesDimension of integrated patient careType of interfaceInterface orientationInterface supporting integration of services
[Lack of protocols]
Lack of protocols for interaction between service providers
Coordination across facilities and support systems
  1. C-C interface

  2. C-C interface

  1. Intra-organizational

  2. Intra-organizational

  1. Planning rules

  2. Planning scheme

[Overlap in services]
Not enough knowledge about other service providers causing overlapping
Coordination across facilities and support systems
  1. C-C interface

  2. C-C interface

  1. Inter-organizational

  2. Inter-organizational

  1. Work description

  2. Service description

[Lack of information transfer]
Lack of tools for information transfer
Coordination across professionals
  1. C-I interface

  2. C-I interface

  1. Inter- and intra-organizational

  2. Inter-organizational

  1. National IT protocol

  2. Open software

[Lack of proactive actions]
Service providers do not actively check with customers whether services are still up to date
Continuous proactivity
  1. C-C interface

  2. C-C interface

  1. Inter-organizational

  2. Inter-organizational

  1. Check-up call

  2. Needs assessment

[Lack of awareness]
Service providers are not aware of the medical history of a customer
Continuous familiarity
  1. O-I interface

  1. Inter-organizational

  1. Multidisciplinary meeting

[Lack of shared professional language]
The information exchanged is documented in a language that is not understood by other service providers involved
Continuous familiarity
  1. O-I interface

  1. Inter-organizational

  1. Standard documentation format

[Lack of common goal]
Lack of common goals for care across the providers
Tailored to the patient's needs and preferences
  1. O-I interface

  2. O-I interface

  1. Inter-organizational

  2. Inter-organizational

  1. Shared care plan

  2. Multidisciplinary meeting

[Lack of transparency]
Overview of care content is missing
Shared responsibility
  1. O-C interface

  1. Inter- and intra-organizational

  1. Overview of available components and modules

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