BACKGROUND:Older adults with multimorbidity often experience fragmented transitional care between the hospital, primary care, and municipal services. Insufficient communication and limited user involvement can compromise safety, satisfaction, and continuity. To address these challenges, a structured cross-sectoral intervention, the Virtual 4-Party Meeting (V4M), was developed to enhance patient and family involvement in discharge planning. AIM:To explore how older adults with multimorbidity and their relatives experienced involvement in transitional care through V4M. METHODS:A qualitative hermeneutic design was applied. Eleven patients ( + 65 years) and their relatives participated in semi-structured interviews immediately after V4M and again 14 days post-discharge. Data were analyzed using Braun and Clarke's reflexive thematic analysis within a Gadamerian hermeneutic framework. RESULTS:Three themes emerged: (1) Bridges between Systems. V4M reduced fragmentation and improved coordination through shared dialog; (2) A Relational Space of Alignment, the meetings created emotional safety and supported patient autonomy and relational understanding; and (3) Involvement and Responsibility are deeply interconnected. Meaningful involvement occurred when accountability was shared between patients, relatives, and professionals. CONCLUSION:V4M provided an effective model for integrating user involvement into transitional care by combining structural coordination with relational engagement. Patients and relatives felt acknowledged, informed, and reassured when professionals gained a clearer sense of shared responsibility. The study highlights that genuine user involvement depends on both emotional recognition and concrete accountability mechanisms across sectors. PATIENT OR PUBLIC CONTRIBUTION:Older adults with multimorbidity and their relatives contributed to the development of the V4M intervention. In this study, patients and relatives participated as interviewees but were not involved in data analysis or manuscript preparation.

AIMS:To map and synthesize which education and training programmes are available for current and future health professionals' competence in virtual consultations, with a special focus on training elements and structure. DESIGN:Scoping review following the PRISMA-ScR framework. METHODS:Studies describing structured education or training in synchronous virtual consultations were included. Data were charted and synthesised to map training modes, educational elements, and terminology. DATA SOURCES:MEDLINE, CINAHL and Scopus (September 2024; updated September 2025). Grey literature was also screened. RESULTS:Twenty-one studies were included. Five training modes were identified: simulation with standardised participants, avatar simulation, peer simulation, in situ training and Objective Structured Clinical Examination. A 5-stage curriculum framework emerged: pre-assess, prepare, conduct, follow-up and post-assess, followed by a catalogue of 34 diverse educational elements. Sixteen different terms were used to describe virtual consultations. CONCLUSION:Evidence demonstrates an increasing focus on virtual consultation training, and a descriptive framework for organising training emerged, however, no consensus exists regarding specific elements, curriculum structure, terminology, or outcome evaluation. IMPLICATIONS FOR THE PROFESSION AND/OR THE PATIENT CARE:The identified framework may guide curriculum development and support competence building across health professions. IMPACT:This review addresses the lack of an overview of how virtual consultation training is structured. It identifies 34 core educational elements and a 5-stage framework. The findings support educators and clinicians implementing training in digital care. REPORTING METHOD:Reported in accordance with PRISMA-ScR and EQUATOR guidelines. PATIENT OR PUBLIC CONTRIBUTION:No patient or public contribution.

Background: Coordination and transitional care are significant focus areas in nursing. A cross-sectoral virtual 4-party meeting (V4M) was established to coordinate and promote quality of care for patients with complex multimorbidity. Aim: To investigate how elderly patients with complex multimorbidity assess their participation in V4M and the impact on everyday life. Method: Qualitative individual first-person interviews with eight patients and three relatives, who had taken part in V4M before discharge from the hospital. The interviews took place up to three months after discharge. Results: Overarching theme, Power and Self-Determination, described how participation fostered control, recognition, and influence. Three themes emerged: Cognition and mastery, Relation and involvement, and Planning and follow-up, followed by seven subthemes: Clarification and influence, Help and independence, Understanding, Dialog, Meeting the GP, Flexibility and visibility, and Shattered expectation. Conclusion: V4M enhances coordination and patient empowerment in transitional care when professionals are prepared and responsive. Sustainable impact requires follow-up and cross-sectoral collaboration.

The escalating prevalence of multimorbidity within aging populations necessitates the development of coordinated healthcare strategies capable of addressing the intricate and interrelated healthcare needs of affected individuals. These strategies must actively enhance care coordination, optimize communication and collaboration among healthcare providers, ensure the seamless continuity of care across diverse settings, and promote greater patient engagement in decision-making processes. A paradigm shift from vertical single-disease management to horizontally integrated care models is necessary for meeting the complex demands posed by multimorbidity. This study aimed to create a holistic approach to the encounter with patients with multimorbidity. Methodology: The research is based on an action research design, wherein healthcare providers, patients, caregivers, and researchers actively participated in a series of four workshops. These workshops serve the dual purpose of identifying prevailing gaps in the extant healthcare system and formulating strategic interventions to address these lacunae. The proceedings of these workshops are meticulously recorded and subjected to thematic analysis. Results: Thematic analysis of the workshop deliberations reveals five salient themes: 1. In-depth Knowledge Acquisition: Emphasizing the imperative of acquiring comprehensive insights into each other's practices and routine to bolster the continuity of care across sectors. 2. Involvement of Patients and relatives: Highlighting the initiation of cross-sectoral dialogues, particularly concerning discharge planning at the hospital level, and addressing the dearth of expectations for the relatives post-hospitalization. 3. Information Accessibility and Meaningfulness: Identifying challenges associated with information exchange across sectors and underscoring the need for disseminating contextually meaningful information. Especially important that they share information they need to know and not only nice to know from the other part. 4. Cross-Sector Collaboration: Expressing the necessity for lucid cooperation and the cultivation of a cohesive culture among healthcare professionals to mitigate misunderstandings. 5. Shared Understanding of Care: Recognizing disparate perspectives between hospital and home care, underscoring the need for a mutual understanding of the care continuum. Conclusion: Based on a co-creative process involving patients, relatives and stakeholders across care sectors, a research-informed circular care approach emerges as a viable solution to enhance cross-sectoral care for multimorbid patients. This approach advocates for relationally coordinated support within a sustainable and coherent framework. The study underscores the dearth of well-established models employing a holistic approach to multimorbid patient care, underscoring the exigency for further research in this domain. Currently, we are testing the circular care approach. An ongoing study will clarify how a circular care approach can be used in integrated care. The framework of this study is a cross-sectoral video conference with patients with multimorbidity beyond their hospital admission. At ICIC24 we will share our experience and results from using a circular care approach.

Purpose This study aims to develop a model promoting integrated care for patients with multimorbidity based on patients’ and healthcare professionals’ needs to share knowledge in cross-sectoral communication and coordination in the local setting. Design/methodology/approach We used an action research design that involved healthcare professionals, patients and researchers. The research followed an interactive process through its four phases. This study focuses on phase two, developing interventions to strengthen integrated care. The data consisted of audio recordings of workshops and field notes. Findings An action research group and invited expert participants contributed to developing 25 proposals for improving cross-sectoral collaboration in integrated care. The fundamental principles were discussed among the action research group. Five key principles were identified to base the CIRCLE-CARE model: (1) collaboration, (2) involving patients and relatives, (3) relationships across sectors, (4) clear communication and (5) embrace knowledge. Originality/value An action research group developed the CIRCLE-CARE model to address the needs of integrated care communication in the local context. The model is ready for future studies of its applicability, impact on patient pathways and healthcare costs.

Background Older adults with multimorbidity experience fragmentation of care. Ensuring optimal use of healthcare services requires stratifying their need for integrated care. We aimed to map existing stratification tools for assessing older adults with multimorbidity in an integrated care context. Methods We searched MEDLINE, Embase, PsycINFO, Cochrane Library, and CINAHL, and extracted definitions of population, concept, and context following the JBI Framework for Scoping Reviews. Results We identified 17,689 articles of which 11 articles were included. Few stratification tools for this population exist and differ on scoring methods, domains and settings of use. Stratification is used for identifying older adults with multimorbidity to multidisciplinary teams or to case managers. Future research should develop stratification tools across sectors focused on the common risk factors of multimorbidity in older adults.

SAFE is a mobile application co-created for and by people who have experienced self-harm, either themselves or as next of kin. This study intended to integrate SAFE into an Emergency Department (ED) to help patients share experiences of self-harm and to support professionals in conducting treatment as usual (TAU). Objective: This study was a part of a Co-operative Inquiry in which a learning intervention was implemented, followed by an interview study exploring ED nurses’ reflections and learnings while integrating SAFE into their practice. Methods: Thirteen semi-structured interviews were analysed using reflexive thematic analysis. Results: The nurses imagined that SAFE could be a positive game changer. However, they were hesitant due to uncertainty about the ED context, the value of the app and their skills. Conclusions: Supplying TAU with technology is challenging and future digital solutions must be created in partnership to ensure the solutions are customised to the target group.

OBJECTIVE:The objective of this scoping review is to explore, report, and map the evidence on education and training programs for current and future health professionals' competence in virtual consultations. INTRODUCTION:Digital solutions, telemedicine, and technologies are increasingly becoming a part of the health system, requiring current and future health professionals to master skills in these domains. INCLUSION CRITERIA:This review will consider any studies on education and training programs designed to optimize current and future health professionals' competence in virtual consultations in any setting, such as faculties, universities, university colleges, hospitals, or community locations. METHODS:This review will be guided by the JBI methodology for scoping reviews. Published and unpublished sources of information will be searched for in MEDLINE (PubMed), CINAHL Complete (EBSCOhost), and Scopus. Studies written in English, German, Danish, Swedish, and Norwegian will be considered, with no geographical or cultural limitations. Two independent reviewers will screen retrieved papers, and a standardized tool will be used to extract data from each included source. The results of the extracted data will be presented in tabular format, together with a narrative summary of the evidence. REVIEW REGISTRATION:Open Science Framework https://osf.io/bsmuy.

Clinical academics experience dual workplaces, namely the clinical and the research environment. However, working in two workplaces leads to difficulties in forming an integrated identity, affecting a person’s work environment and well-being. The aim was to explore how clinical academics experience the psychosocial work environment and their suggestions for improving and changing work well-being. A multicenter qualitative approach with group interviews inspired by participatory action design was used. A purposeful criterion sampling strategy was used, selecting researchers affiliated with the university’s research network (n = 12). Data were analyzed by thematic analysis and the consolidated criteria for reporting qualitative research was applied. The main finding, ‘lack of integration of research in clinical practice’, revealed how clinical academics balanced between the two practices, how their need for belonging in both work environments was established by fellowship, and how motivational factors and role models could be enhanced through a joint commitment of responsibility in research units and clinical practice. This study provides a contemporary understanding of the challenges that mainly Ph.D. students encounter and what solutions they would offer. This study adds to knowledge on well-being in psychological work and provides solutions on how clinical academic Ph.D. students can achieve the integration of research in clinical practice.

Background: As in many countries, Danish health care intensively focuses on improving cross-sectoral collaboration between the sectors: general practitioners (GP), municipalities, and hospitals. Collaboration between the sectors is often siloed and fragmented, making it challenging to coordinate and plan the patient's transition across sectors. The issue is exacerbated by the increasing number of complex multimorbid patients who need specialized treatment across sectors. Health professionals (HP) must engage in circular thinking, focusing on the patient's needs and involvement. To strengthen cross-sectoral collaboration with the multimorbid patient, we have designed a model for cross-sectoral hybrid video conferencing (Cross-sectorial Hybrid Video Conferencing, CHVC) during the patient's admission at the hospital. The patient, relatives, and HP from the hospital were physically present in the patient's ward. HP from the municipality, GP, and relatives participated by video link on a video screen. We examined if and how CHVC can strengthen collaboration and coordination across sectors. Method: The CHVC was developed in a participatory design with HP from hospitals, municipalities, researchers, and patient and relatives' representatives. The meetings lasted a maximum of 30 minutes and started with questions for the patient and relatives: What is important to you? What do you expect from the admission? What worries you and your family? Subsequently, we asked HP about what they found worrying and their expectations of the patient's admission. Inclusion Criteria: aged 65+, complex multimorbid patients with a need for municipal help before and after admission, and health professionals with knowledge of and responsibility for the patient's care and course of treatment. The video meetings were audio recorded and transcribed into text. Researchers carried out content and thematic analysis. Result: We conducted 11 CHVC. The overall theme is a negotiation between patients, relatives HPs and GPs. They negotiated about how the patient could be at home despite a fragile and unstable situation. In addition, there was a negotiation regarding the discharge date. The discharge date was negotiated from the perspectives of the HP and GPs opportunities to support the patient's care and treatment needs at home. Discussion and Conclusion: The health professionals across specialties and sectors, together with patients and relatives, exchanged knowledge essential for the patient's safe and satisfactory discharge and subsequent care course. A noteworthy finding in our study is that, during CHVC with the patient's needs as a starting point, the health professionals included their worries about the patient's overall situation and their expectations for the patient's hospitalization. This resulted in dialogical communication in which they asked questions about each other's practice and collaborated on a joint plan for the patient. The hybrid, interdisciplinary, cross-sectoral dialogue between the four parties gave the patients safe transitions and care paths. It is our experience that CHVC is a medium by which negotiation about the patient's course can strengthen coordination and collaboration between sectors. However, this study was limited to 11 patient pathways; in future research, we will test CHVC for 200 complex multimorbid patients admitted to a regional hospital in Denmark.

OBJECTIVES:To better comprehend the initial injury experience and care requirements of knee-injured individuals, as well as healthcare professionals' interactions with early care.DESIGN:Qualitative interviews.SETTING:Public healthcare in Denmark.PARTICIPANTS:Ten individuals (6 women) with major knee injuries (6 anterior cruciate ligament (ACL) and meniscal tears, 2 isolated ACL tears, 1 isolated meniscal tear, 1 patella dislocation), aged 16-33 years (median 19 years), 1-26 months post-injury (median 3 months). Thirteen HCPs (5 physiotherapists, 5 orthopedic surgeons, 3 general practitioners).MAIN OUTCOME MEASURE:Semi-structured individual and focus group interviews, transcribed verbatim and with latent thematic analysis.RESULTS:The three main themes were: 1) Emotional struggles in solitude - knee-injured individuals dealing with emotions alone due to limited HCP resources for emotional support. 2) Blurry beginning - knee-injured individuals finding initial care frustrating, a sentiment shared by HCPs. 3) A journey with no map - knee-injured individuals holding varied outcome expectations, while HCPs hesitate to discuss long-term knee health.CONCLUSION:Early care for knee-injured individuals is filled with worries and unmet emotional and information support needs. HCPs need more support and training to deliver timely and appropriate care.

Background: ‘The Body Multiple: Ontology in Medical Practice’ is the title of an influential ethnographic study of health care practices (1). As the title conveys, disease is not just one thing, but have different meanings related to the various medical practices involved, and thus the ontology of the body becomes multiple! As in the case of patients with multi-morbidities and chronic diseases (MCD), the multiplicity of their bodily illnesses turn them into complex patients, involving many health care practices. Providing care to frail elderly with MCD is a ‘wicket’ problem because of the clinical complexity, the social complexity and the system complexity (2;3) that follow from the many care needs. The collaboration between the providers, patient and relatives are pushed to its edges. Expanded coordination of the care paths of frail elderly is called for to make transitions safer, alongside with the acknowledgement of patient involvement in ‘circular care’ arrangements, where the sectors collaborate on the MCD patients’ ongoing needs (4). Method: Participatory design with third space learning (5) between the sectors via the use of Video for Cross-sectorial Virtual Conferencing, (VCVC). The participants represented four different knowledge-practices of care, i.e. the family home, the municipality, general practice and the hospital. The VCVC was conducted from the hospital who included 20 elderly patients with MCD. Eleven video-meetings were video-recorded and transcribed verbatim. The hybrid dialogues between patient and health care professionals at the hospital (HPH), the municipality (HPM), the family doctor (GP) and relatives was framed in a collective mail-invitation with a 30 minuts timeslot, video-link and instructions. In total 64 participants: 11 patients, 16 relatives, 14 HPH, 13 HPM and 10 GPs. Results: The use of video for cross-sectorial collaboration on complex patients' care needs becomes a third-space-of-learning, and of expanding relational coordination. Analysis of the video-recordings show patterns of interaction at different levels, that in total created unique, patient-tailored care plans. One pattern comes from the need of moderation to secure inclusion, turn taking, and closure in the virtual setting of communication. The other pattern arose from the interaction between the four knowledge-perspectives on the patient’s situation, i.e. the perspective of the hospital, of the GP, of the municipality and of the family home into a new totality of understanding. Discussion: The hospital nurse plays a leading part in including the patient’s voice and wishes. S(h)e also ensures that all contextual perspectives are included, to sum up agreements and documentation. The circular discourse of knowledge exchange between the participants take-off from the patient’s wish, e.g. “come back home”. The hospital doctor follows with a clinical opinion on a specific medical problem. This speech act resemblances “doctors’ rounds”, but is cut short from the virtual others’ perspectives on the patient’s situation. Especially from the GP' questions about other medical conditions. This question open up to a new, circular form of discourse were GP, municipality and relatives complement each other’s perspectives with new information that in sum add to the whole understanding of the patient’s situation, and circular care needs. References (1) A.M. Mol (2002). The Body Multiple: Ontology in Medical Practice. Duke University Press. (2) P. Kuipers; E. Kendall; C. Ehrlich; M. McIntyre; L. Barber; D. Amsters; M. Kendall; K. Kuipers; S. Brownie (2013). Complexity in healthcare : implications for clinical education. Focus on Health Professional Education; v.15 n.2 p.4-16; October 2013, 15(2), 4–16. https://search.informit.org/doi/10.3316/aeipt.201585 (3) J. Amblàs-Novellas; J. Espaulella; L. Rexach; B. Fontecha; M. Inzitari; C. Blay; X. Gómez-Batiste (2015). Frailty, severity, progression and shared decision-making: A pragmatic framework for the challenge of clinical complexity at the end of life. Palliative medicine and care. European Geriatric Medicine. Volume 6, Issue 2, April 2015, Pages 189-194 (4) D. Høgsgaard et al. (Submitted for peer-review) Development of the Circular Care Model to improve cross-sectoral and interprofessional collaboration for patients with multimorbidity. An action research study. Journal of Interprofessional Care. (5) M. J. Muller; A. Druin (2002) Participatory design with third space learning. https://www.researchgate.net/publication/228398475_Participatory_Design_The_Third_Space_in_HCI

People with coexisting type 1 and 2 diabetes and mental illness have a higher mortality rate compared to the general population, among other reasons due to unregulated diabetes. One explanation might be the complexity of managing both conditions. In this interview study, we explored the accounts of delivered diabetes and mental health care of 16 individuals living with coexisting diabetes and mental illness in Denmark. A thematic analysis by Braun and Clarke was applied in the analysis. Some of the participants described the care for diabetes and mental illness to be inextricably linked to each other. Therefore, health care providers ought to focus and knowledge of both conditions as essential components in the care provided. The participants accounted for support needs in other settings beyond diabetes and mental health outpatient clinics, such as the family doctor, residential institutions, and community care. However, the inefficient collaboration between these health care settings is one of the barriers to supporting the participants' self-management.

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

Aim The objective of this scoping review was to summarize, understand and provide an overview of the empirical literature on interventions involving own treatment choice for people with coexisting diabetes (type 1 and 2) and severe mental illness (SMI). Methods This scoping review undertook a systematic literature assessment. Searches were performed in MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, the Cochrane Library and grey literature (OpenGrey, Google Scholar and Danish Health and Medicine Authority databases). Publications from 2000 to July 2020 were of interest. Studies were included if they involved the users' own choice of treatment. Included studies: RCT, intervention, cohort and case-based studies. Results A total of 4320 articles were screened, of which nine were included. The review identified eight studies from the United States and one from Canada testing different interventions for people with SMI and diabetes (one diabetes education program, five randomized controlled trials, one retrospective cohort study, one naturalistic intervention program and one case vignette). The interventions described in the nine articles involved service users, the majority incorporated individualized healthcare plans, and all interventions were based on multidisciplinary teamwork. Conclusions Research in the area is limited. Care management interventions tend to focus on a single condition, paradoxically excluding SMI during enrolment. Interventions aimed at people with both conditions often prioritize one condition treatment leading to an unbalanced care.

Aim to:• investigate how citizens with 1 or more chronic conditions, patients, and their relatives experience the cross-sectoral cooperation in their disease course (Study I).• develop and test cross-sectoral collaboration models that can strengthen - and promote coherence and quality in the intersectoral and general practice of citizens and patients (Study II + III)• examine the significance and effect of the collaborative cross-sectoral collaboration models - including the importance of the tested models for the quality of contexts, the number of inappropriate re-admissions and the patients' experience of the cross-sectorial collaboration (Study IV).This is a postdoc project (2019-2022) consist of 4 sub-studies. This paper only presented results from the first study.Background: Research had shown that it is a complex and difficult task to create well-functioning interdisciplinary and cross-sectorial coherent care, treatment and rehabilitation programs for multimorbid patients. In addition to insufficient cross-sectorial collaboration on patient care for patients and their relatives, it can also result in longer admissions and inappropriate re-admissions - and thus a waste of resources in a health care system under pressure. Despite many years of focus on improving cross-sectoral collaboration and coherence in the course of patients - this remains a major and increasing challenge. Today, patients' hospitalization is often short and intensive and their care, treatment, and rehabilitation tasks must often be continued and completed at general practice and/or in the municipal health care system. For the future healthcare system to function satisfactorily, one of the prerequisites is to ensure patient transitions to create the best conditions for a total responsibility for the patient to be taken.Design and Methods:The design is action research. Patients and relatives, as well as the health care professionals (from hospitals/municipalities), are involved as informants and in the analysis work.The target group: +65-year-old patients with 1 or more chronic conditions who receive home care service from the municipalityIn study I, semi-structured interviews are conducted during the 13-16 patient's hospitalization. Patients are re-interviewed approx. 14 days after discharge. Content analyze will be conducted. Ethnographically inspired field analyzes are carried out, where the interviewed patients are followed by follow-up visits to GP and/or outpatient visits to the hospital. Accidental events will be analyzed. In Aug-Oct 2019, a questionnaire survey will be conducted. Based on the empirical material, creative non-fiction narratives are constructed. The narratives will be analyzed by patients, health care professionals, and researchers.Expected results: It is expected that the collaborative processes between patients/relatives, health care professionals, and researchers can create knowledge about how patients in this context experience the cross-sectoral collaboration. Their ideas and suggestions for new models will be included in the following collaboration work (study2). This study will also provide knowledge on how patients and relatives can be involved in the research processDiscussion: This project is ongoing. Results and discussion will be presented at the ICIC-conference 2020

Background: People often experience failure in communication and lack of coordination leading to worsening of illness, and frustration treated in several healthcare-sectors. It also often leads to increased use of healthcare- resources. Increased specialisation and different management-paradigms have somehow changed focus from the general care and the need of those who need it the most. At NSR Hospital, the readmission rate for acute somatic admissions is among the highest in Denmark. From Slagelse Municipality, the readmission rate is very high too. In Slagelse the municipality, general practice and both the psychiatric and the somatic hospital have high ambitions for the locale cross-sectorial-collaboration and want to establish collaborations, which provide patients with good experiences. The project ”Cross-sectorial whiteboard-meeting” was establish after an analysis of the challenges in the cross-sectorial-collaboration. Therefore, a meeting every two weeks between Slagelse Municipality, General Practice and NSR Hospital was trialed. There was special focus on readmission within five days. Hypothesis: We expected that the systematic analysis and the following testing of workflow in the cross-sectorial-collaboration would reduce readmission and secure good cross-sectorial patient-trajectories with equally high quality with the person in the center and with the right use of resources in the right sector. Method and design: We used Improvement Science. Data was up-to-date, and Plan-Do-Study-Act-circles were used to change the workflow. The model: What do we wish to achieve? When do we know that a change is an improvement? Which changes do we want to try? Testing of changes: The chosen changes suggested at the whiteboard-meetings were a continuous development of the cross-sectorial-collaborations. Implement changes: We implemented the changes, which showed good effect in existing workflow to benefit for all admitted patients. Assessment: Interview with health-professionals evaluating the outcome of their work with people often admitted to hospital. Results: The team: Participants in the whiteboard-meeting must be relevant for the problems. The participants were : From NSR Hospital: two deputy directors, five leading head-nurses, 1 leading therapist and four from the administration. From the municipality: Health-director, health-development-consultant, health-coordinator, head of visitation, acute-team-leader and a consultant for psychiatry and handicap. From the psychiatry in the Region: two head-nurses and one head consultant. One General Practice consultant. Citations from participants in the cross-sectorial whiteboard-meeting: Municipality-leader ”The meeting makes so much sense. I tell my colleagues that in the hospital they work seriously with preparing the discharge. It means a lot to follow the initiatives taken to improve the discharge-process. It makes my colleagues optimize their part of the collaborative–process”. Hospital-case-manager ”The meetings are an opportunity to exchange necessary views on the discharge-process. It is very valuable to hear what the municipality finds we can improve on. We exchange views and get an understanding of each other’s’ challenges.” Hospital-leader ”These meetings are more than just meetings where we orientate each other of problems with the transitions between sectors and readmissions, Here we focus on learning from the action. It is meaning-creating and contributes to improvement. It rocks”. At the conference, we will elaborate on the study-outcome.