Health & Welfare

Changing demographics and an increasing elderly population who live longer with chronic diseases pose many challenges for the healthcare system. Part of the solution is to enable care at home whenever possible. In Oslo, the municipality offers Digital Homecare – a service for patients living at home with chronic diseases. The service allows patients to remain at home while being followed up by healthcare personnel from a local healthcare unit.

For the service to work well and provide a safe and smooth experience for patients, it is essential that collaboration and communication between specialist healthcare (at hospitals) and primary healthcare (with general practitioners and local healthcare units) function seamlessly. This challenge became even more urgent as Oslo Municipality planned to implement the service in additional boroughs. How can we ensure a cohesive patient journey and make transitions between stakeholders work effectively?

Implementing and scaling a service in a complex organisation

Implementing services in complex, cross-organisational contexts, such as healthcare, requires investing time and effort into collaboration and establishing common ground. As external consultants, we collaborated closely with different stakeholders – hospital staff, primary healthcare staff, and representatives from Oslo Municipality – and facilitated the dialogue between the groups. 

Through workshops, facilitated meetings, and gathering 

 from healthcare personnel across departments, we helped them define and clarify roles in the patient 

. Who is responsible for each step, where do the transitions occur, and how? How can we best create awareness around the service among hospital staff to ensure that all qualified patients are offered the service?


User insights

User Journey

Together with stakeholders, we developed:

Guidelines for patient referral routines from hospitals to Digital Homecare.

Clarification of responsibilities in the process of transferring and following up on patients.

Citywide routines with clear role and responsibility distribution, along with step-by-step descriptions of tasks to be maintained throughout the service journey.

Starter kit for boroughs implementing the service.

Information materials, events, topic-specific courses, and presentations about the service to increase awareness.

Course in digital homecare for GPs (general practici.oners) and other healthcare staff.

Routine guidelines and facilitated communication

The digital home care is tailored to each patient, considering their specific health situation and context. Common measurements that are monitored are pulse, oxygen saturation, blood sugar levels and blood pressure, often in combination with question that the patient answers. The results are followed up by healthcare staff at a local primary care centre. Photo credits: Dignio.

The facilitation process has strengthened the collaboration between boroughs, where sharing experiences has allowed them to learn from each other and improve the service. With citywide routines and a starter kit with clear guidelines and role distributions, we have enabled a unified implementation and operation of the service across boroughs. Awareness of the service has also increased significantly through information campaigns and the involvement of representatives from both specialist and primary healthcare.

The result is a more cohesive service approach and patient journey, enabling more efficient use of healthcare resources and providing data-driven decision support. Patients who can receive care at home benefit from closer follow-up, with increased security, empowerment, and knowledge.

Implementation and scaling of Digital Homecare