Abstract
INTRODUCTION: The aim of the TELEKAT project (‘Telehomecare, chronic patients and the integrated healthcare system’) is to develop and test a preventive home monitoring concept across sectors, enabling patients with chronic obstructive pulmonary disease (COPD) to avoid readmission to hospital and perform self-monitoring and to maintain rehabilitation activities in their homes. COPD patients with severe and very severe COPD are included in the study. THEORY: Inter-organisational theory and learning theory. METHODS: The case study approach was applied in a randomised study (n=111). The data included documentary materials, participant-observation (163 hours), qualitative interviews with healthcare professionals (n=41) and COPD patients (n=64). RESULTS AND CONCLUSIONS: Providing preventive telerehabilitation for patients with COPD is a cross-disciplinary effort involving various professionals. In the view of both COPD patients and healthcare professionals (GP, district nurses, healthcare professionals from healthcare center and hospital), telerehabilitation helps patients to become more aware of development of their own symptoms; to contact the GP early on in order to start treatment plans; avoid admission to hospitals; integrate and maintain changes of lifestyle in their everyday life; and adds a feeling of security to patients with a very severe COPD. Healthcare professionals have adapted new approaches for empowering COPD patients and a more integrated collaboration across sectors.