Purpose: To use general policy guidelines and staff experience of rehabilitation work in two boroughs in Oslo to develop a model for organisation and cooperation in home-based rehabilitation.
Method: The project was conducted as a collaboration between researchers and employees in the two boroughs. It was a practice-oriented study designed as an action research project combining knowledge generation and improvement of practice. Data were collected at seven meetings, and individual, qualitative interviews with a total of 24 persons were conducted in the period February 2010 to June 2011.
Results: Home-based rehabilitation occurred rarely in the boroughs, and this field received little attention. However, this project provided a broad discussion of rehabilitation involving all parts of the organisation of both boroughs. In the course of the project, researchers and borough staff together developed a model for the organisation of and cooperation on rehabilitation including a coordinating unit assigned the paramount responsibility for the rehabilitation and an interdisciplinary team organising the collaboration on the practical level.
Conclusions: When implementing a model like this in primary health services, we recommend involving several levels and service locations of the borough staff in order to legitimise the model in the organisation.
Implications for rehabilitation: An increasing number of older people with chronic diseases in the Western world have caused increasing emphasis on rehabilitation in primary health care in patients' homes. This study has elucidated challenging framework conditions for rehabilitation work in two Norwegian boroughs. To reduce municipal challenges we propose a rehabilitation model with a coordinating unit with the paramount responsibility for rehabilitation, and an interdisciplinary team constituting a suitable structure for collaboration.