Patient Centered Healthcare Teams


The multi-disciplinary Patient Centered Healthcare Teams have been established in several municipalities in Northern Norway. The teams aim to strengthen health care services for frail and multi-morbid elderly. The teams are a collaboration between the hospital and the municipalities and follow-up patients with chronic and complex conditions who are discharged from hospital.

Patient Centered Healthcare Teams

The Patient Centered Healthcare teams were established with the aim of improving the continuum and quality of the care of frail elderly patients and the focus is to ensure a safe discharge and prevent hospital admissions. The teams represent a new service model as they work between primary and secondary care, with staff from both community services and the hospital, and thereby produce new relations and work practices. The teams conducts home visits and visit hospitalized patients.[1]

The Service

The RemoAge project works with the Patient Centered Healthcare Teams in our region to develop e-health services to support the teams’ work. Technology implemented is tablets and videoconference within the secure Health Network.

The service is designed to promote effective communication, knowledge sharing and coordination of care across the healthcare system.

Tablets are used byteam members to:

  • Support the planning of follow-up of patients by filming the patient at home, saving pictures to record the development of the patients’ condition and consultation over videoconference with other team members or other health professionals
  • Receive advise in the patients’ home from other team members and other health professionals over videoconference and the sharing of pictures and films
  • Clarify further treatment in elective and emergency situations over videoconference
  • Carry out supervision of patients at home over videoconference.


The service contributes to improving the flow of information and interaction within the team, with external healthcare professionals and with patients. Health care resources have been saved because patients’ and health professionals’ travels have been avoided.

[1] Trine Bergmo et al. Patient –Centred Health Care Team. Work Practice, Experiences, and Estimated Benefits. IARIA, 2016
(eTELEMED 2016).