Implementing cross-sector hospital-at-home treatment: challenges, opportunities and action research insights

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This paper investigates the implementation of a cross-sectoral admission avoidance hospital-at-home model in Denmark, developed collaboratively by a hospital emergency department, three municipalities, and general practitioners. The model aims to provide acute medical care to elderly patients in their own homes, minimizing hospital stays, and reducing risks associated with hospitalization. Employing an action research approach, this study captures the dynamic process of implementing the hospital-at-home model. The methodology emphasizes iterative learning cycles, collaborative problem solving, and stakeholder engagement. The implementation process is analyzed using policy implementation theory, with a focus on an interplay between inter-organizational behavior, leadership, and front-level staff roles. The findings highlight the importance of trust, communication, and flexibility in fostering effective cross-sectoral collaboration. Practical tools, such as structured task descriptions and regular dialogue and reflection meetings, proved instrumental in overcoming barriers and aligning diverse stakeholder practices. Challenges, including logistical complexities and resistance to role changes, were addressed through real-time adjustments facilitated by the action research approach. This study provides actionable insights into the implementation of hospital-at-home models, emphasizing the value of cross-sectoral collaboration and iterative learning. The findings underscore the potential of such models to improve care quality for elderly patients while alleviating pressures on healthcare systems. Future research should focus on evaluating long-term outcomes and exploring scalability in diverse settings. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction As healthcare systems grapple with the pressures of an aging population, innovative solutions are needed to address the rising demand for acute care. Hospital-at-home models have emerged as a promising alternative, offering hospital-level treatment within the patient’s home. This approach minimizes risks associated with hospitalization, such as infections and functional decline. However, implementing such models requires overcoming significant organizational challenges. This paper examines these complexities through an action research study, shedding light on the processes, opportunities, and obstacles encountered in establishing a cross-sectoral admission avoidance hospital-at-home model in Denmark. Healthcare systems today face great challenges, e.g., the demographic challenge of a fast-growing ageing population. In Denmark, the total number of hospital days per year is expected to increase by 42% between 2013 and 2050, from 4.66 to 6.72 million days, and the largest change is expected to occur for the population aged 70+ (Oksuzyan et al. 2020). However, hospitalization is not always the best solution for elderly patients. Emergency admissions can disrupt daily routines, increase the risk of infection and delirium, and lead to physical and mental decline, which may take a long time to recover (Covinsky et al. 2003; Creditor 1993; Inouye et al. 1999; Strausbaugh 2001). Furthermore, many elderly acute medical patients are admitted for a short period in order to undergo comparatively uncomplicated treatment, which in many cases could have been avoided, if alternatives had been developed (The national association of municipalities 2013). Finding alternatives to hospitalization is increasingly necessary. One such alternative, developed in many countries around the world, is the hospital-at-home model, which is rapidly growing (Sheppard et al. 2016). In this model, healthcare professionals provide hospital-level care in patients’ homes for a limited period, treating conditions that would typically require acute hospital inpatient care. These services are often aimed at elderly medical patients and can be organized in various ways. Two main types of hospital-at-home models have been identified. In the early-supported-discharge-model, patients are discharged early and continue treatment in home, while in the admission-avoidance-model patients avoid physical contact with the hospital and are directly treated at home based on general practitioner referrals (Leong et al. 2021). These models vary in terms of illnesses treated, patient acuity, admission sources, treatment team composition, and the level of physician and nursing care provided (Leff 2009; Shepperd et al. 2016; Vale et al. 2019). Previous studies about hospital-at-home models have demonstrated significant reductions in mortality, readmission rates, and costs, along with better patient and caregiver satisfaction compared to in-hospital treatment (Caplan et al. 2012). Although hospital-at-home models have several strengths, their inherent complexity presents challenges for implementation (Leong et al. 2021). The implementation of hospital-at-home models has been explored in previous research. For instance, Brody et al. (2019) conducted focus groups to analyze retrospectively and recall the implementation process, offering insights into the challenges and successes encountered. Rothman et al. (2024) examined the process of building and implementing a hospital-at-home model, providing a comprehensive guide on the necessary steps, from initial planning and resource allocation to the integration of clinical services and patient care protocols. Wallis et al. (2024) went through 52 qualitative studies exploring the implementation of hospital-at-home services and found four themes: development of stakeholder relationships and systems prior to implementation, requirements for safe and effective implementation, acceptability and caregiver impacts, and sustainability of services. Still, more research about implementation of hospital-at-home treatment is needed (Leff et al. 2022). In this paper, we will report on a study that investigates an admission avoidance hospital-at-home treatment pathway and how it was implemented. In 2018, a hospital emergency department (ED), three municipalities, and general practitioners (GPs) decided to collaborate with the aim of reorganizing the treatment of elderly patients in order to create a hospital-at-home pathway. Through the collaboration, they wanted to create a better option for the elderly acute ill patients and at the same time handle the demographic challenge. Collaboration is a process in which parties with a stake in a problem actively seek a mutually determined solution. It involves overcoming many barriers, particularly when it spans various organizations (Bøllingtoft et al. 2012). Thus, implementing a cross-sectoral admission avoidance hospital-at-home treatment model is expected to be challenging, when three healthcare organizations collaborate. However, collaboration is essential in situations where a shared goal can only be achieved by a group of actors, each contributing complementary efforts to a larger system in a coordinated manner (Gray 1985). This is crucial in reorganizing care of elderly patients, who need treatment from multiple professions across different organizational units and sectors. Successful collaboration is key to co-creating a new organizational model for hospital-at-home treatment, as it requires employees to adapt practices and work together effectively (Duvald 2021). To facilitate and follow the process with developing and implementing the new organization for hospital-at-home treatment in a collaboration with multiple different stakeholders, an action research approach was chosen. As Bradbury and Lifvergren (2016) note: action research in healthcare shifts the focus from traditional expertise to distributing authority among stakeholders across multiple complex systems, and engaging participants in reflecting on their experiences. This method is suitable for involving all occupational groups in patient treatment to collaboratively discuss and negotiate the best course of action. Using an action research approach, the study captures iterative learning cycles that facilitated the co-creation and refinement of the hospital-at-home model. The aim is to generate actionable insights into the processes and dynamics of implementation in a multi-organizational healthcare setting, emphasizing the roles of inter-organizational collaboration, leadership, and frontline staff. These findings offer practical guidance for improving the design and execution of similar initiatives in complex healthcare environments. The following section frames implementation as a process, drawing on policy implementation theory to analyze the development and adoption of the hospital-at-home model. Theoretical approach: implementation as a process Within health research, implementation science is often used as the primary theoretical lens to understand implementation of new activities in health care organizations. However, implantation science often focuses on the perspective of the healthcare professionals’ perceptions and experiences and leave out other perspectives when understanding implementation processes (Nilsen 2013; Nielsen 2021). We therefore turn to policy implementation theory that allows for a broader focus on multiple types of actors and organizational perspectives. The implementation of new policies and interventions within the public sector has been studied within social sciences since the 1970’ties, where the first studies reported on the difficulties of making planned changes happen in practice (Pressman and Wildawsky 1973; Bardach 1977). The early development of theory focused on top-down and bottom-up perspectives respectively (Winter 2006). The first with a focus on exploring how policy development, law, and hierarchical implementation structures provide opportunities and barriers for implementing planned changes (e.g. Mazmanian and Sabatier 1981). The second with a focus on studying how the front-level staff often play a crucial role in making decisions on how changes can be implemented in practice (Lipsky 1980; Elmore 1982). Today, the two perspectives are still predominant perspectives in the theoretical understanding of implementation, but over time, the perspectives have been synthesized into models that recognize the co-existence of both top-down and bottom-up perspectives (Greenhalgh 2004; Winter 2006; Nielsen et al. 2022). One such integrated implementation model building on various theories has been developed by Winter (Winter 2006; Winter and Nielsen 2008). Figure 1 shows the various elements in the model. This model is based on a process perspective; that the implementation of an intervention consists of different phases, including designing, implementing, and a result. It can be used to analyze the implementation process and why the implementation may succeed or fail. The model illustrates how the initial decisions concerning design of a change, in this case the decision on establishing a cross-sectoral admission avoidance hospital-at-home model, sets a framework for the implementation process, and thus partly defines the background for potential barriers and opportunities in the implementation process. Thus, design is about what preceded the implementation, and what implication this has for the implementation process. The design of the hospital-at-home model is described elsewhere (Duvald 2021). In this paper, in the analysis we will zoom in on the particular part of the integrated implementation model that describes the implementation process. Based on prior studies of implementation processes, the model identifies four elements, which influence the output and outcome of the process (Winter and Nielsen 2008). Organizational and inter-organizational implementation behavior: The behaviors of organizations are key to results of an implementation process. Often implementation processes include different authorities and organizations with different interests. They typically have opportunities to promote or distort the intentions behind the interventions, and the behavior often constitutes a complex interplay between these interests. Leadership has a significance when organizational objectives are transformed into behavior among front-level staff. The role of leadership for transformation is typically affected by the potential information asymmetry between leaders and front-level staff, and the instruments that are used by leaders to assure the transformation. Front-level staff are assumed to play an autonomous role in relation to the output and outcome of the implementation process. The staff often make a substantial discretion when it comes to the decision on how to deliver public services to the target group of the intervention and is therefore often referred to as ‘the real decision makers’. There may be differences between employees depending on their sense of ownership of the intervention, their perceived workload, their attitudes and knowledge, and the situation. The target group behavior is considered crucial for the output and outcome of the implementation process. The target group often interacts with the front-level staff in joint-production of the services delivered and thus has an impact on the results of an implementation process. In the model, performance refers to the changed behavior among the actors in the implementation process. Finally, the environment, e.g. the time or political changes, including any changes that may occur in the environment, often influences the implementation process. In the analysis of the implementation process, we have decided to focus on the interplay between the organizational and inter-organizational implementation behavior, the leadership, and front-level staff behavior. In this project, it is a decision of physicians, if the patient is offered treatment in their own home. The patients as the target group prefer to be and accept hospital-at-home treatment. To closely follow and facilitate the implementation process, an action research approach was chosen, enabling collaborative problem-solving and iterative learning. Furthermore, this approach creates the opportunity to implement the pathway directly, because the healthcare professionals themselves test whether the pathway works and makes sense in their practice. Methodology: Action research Action research is a philosophical approach, with a methodological framework where researchers and practitioners collaborate closely with two objectives, to solve a problem and at the same time contribute with new knowledge (Shani and Coghlan 2021). It aims at generating practical knowledge for practice that is also robust for scholars. As research that is taking place concurrent with action it consists of iterative cycles of action and reflection, larger and smaller, consisting of four basic steps or phases: constructing, planning action, taking action, and evaluating action. In the constructing phase, the focus is on mapping the past and present in order to be able to contribute to changing the future. In the planning action phase, the actors move from what they are doing now to what they believe should be doing in the future. In the taking action phase, the concrete actions that researchers and practitioners have come up with, which they would like to test in practice together, are carried out collaboratively and implemented. In the evaluating action phase, the final evaluation of the taking action phase and the process of changing practice takes place, including both intended and unintended outcomes (Coghlan 2019). In this paper, we will focus on the taking action phase, in which the hospital-at-home treatment pathway was implemented. Action is central because the starting point for learning, development, and change is based on joint experimentation with testing new actions created through joint dialogue aimed at addressing issues and solving problems (Coghlan 2019). Action is created by and leads to dialogue and critical reflection, and on that basis, new insights and knowledge are created. When the changes are initiated and tested over time, the implementation takes place at the same time that participants and researchers develop, test, and adjust the new way of working. Thus, as action research is understood to be taking place in the present tense on live issues, implementation is a key process as addressing how the issue unfolds and learning and practical is generated. Within this experimental implementation process, the action researcher works closely with the practitioners and is the facilitator of conversation and of emergent learning/knowledge cogeneration (Shani and Eberhardt 1987). The practitioners contribute their experience and knowledge of their own practices, while the researcher contributes their skills in facilitation, methodology, analysis, and process oversight. Through the cyclical process of action research, reflection and learning are initiated, leading to the creation of new knowledge (Coghlan 2019). Coghlan and Shani (2014, 2018) offer a framework of four factors to enable the quality of an action research initiative to be assessed. First, it needs to be demonstrated how socio-political, commercial and cultural forces are driving the need for the issues to be addressed and for knowledge to be generated. Second, the quality of collaborative relationships between participants in the action and the research is paramount. Third, the quality of how action and inquiry progress together through cycles of action and reflection as the project is progressing. Fourth, demonstration of the dual outcomes of a) improved organizational practice, and b) the creation of practical knowledge through the action and inquiry. The following case provides a detailed account of how the hospital-at-home model was developed and implemented through action research, offering practical insights into the complexities of cross-sectoral collaboration in real-world settings. Description of the case The first taking action phase The action research project was initiated in February 2018 and is still ongoing. This paper describes the results from the first taking action phase, in which the hospital-at-home model was tested and implemented, while the previous phases in the project, the constructing and planning action phase, will briefly be summarized, but are described in detail elsewhere (Duvald 2021). Figure 2 illustrates the various phases in the project following Coghlan and Shani’s framework. An anthropologist, who has been studying organization design challenges within the emergency health care field, and has been affiliated with the ED since 2014, was asked to facilitate the co-creation process as project manager. She is the primary researcher at the project. Thus, having access to both information and individuals that would most likely not be available to an outside researcher. The first author of this paper is the project manager but named the researcher in the rest of the paper. In the construction phase, an inter-organizational steering committee and a task force were established. Moreover, the researcher explored the existing collaboration between the ED, municipalities, and GPs though an extensive fieldwork. The results of the fieldwork were presented for the steering committee and task force to create a common and a holistic picture and understanding of existing collaboration (the existing situation and operating procedures) among the practitioners and make the collaborators aware of the dependence on each other and thus qualify the planning of the new way of collaboration. The joint (practitioners and researcher) discussions about where to improve, and how to design the hospital-at-home treatment pathway. The planning phase consisted of workshops and task force dialogue meetings. ED physicians and nurses, municipality nurses, GPs, and an EMS service physician were invited to participate in workshops. Based on their experiences, they generated ideas about and explored collaborative how to design the hospital-at-home pathway. The task force continued to work with the employees’ ideas and planned, with input from the steering committee, how the patient pathway and cross-sectorial collaboration should be organized, so that it could be tested and implemented in one municipality in the first taking action phase. The taking action phase was divided in two phases in the project. This paper describes the results from the first taking action phase, in which the hospital-at-home model was tested and implemented in two municipalities, both the facilitated change (the organizational design of a hospital-at-home treatment pathway), and the learnings by studying the co-creation and implementation process from an outsider-perspective. In the second taking action phase, the hospital-at-home model will be implemented in the last municipality. When the model is offered in all three municipalities, data for the final evaluation will be collected. The aims of the first taking action phase were to test the organization of the pathway by implementing it and treating 50 patients in their homes. This phase aimed to adjust the organization decided at the desk to real-life practice, making necessary adjustments before implementing the pathway in all municipalities and starting up a RCT study to evaluate the hospital-at-home treatment pathway. Additionally, it sought to test whether the data required for the evaluation phase, particularly the quantitative data, could be collected. Finally, the phase aimed to study the inter-organizational collaboration between hospitals, municipalities, and GPs at the various organizational levels. The collaborating organizations This action research study was conducted in Denmark, involving collaboration between an ED, three municipalities, and GPs. Denmark’s free, tax-funded healthcare system ensures all citizens have unrestricted access to GPs and hospital care. The ED at Viborg Regional Hospital is one of five public emergency hospitals in Central Denmark Region that receive trauma and critically ill patients. The region covers 13,142 km², with a population of 1,282,000, including approximately 233,000 residents in the Viborg area, which encompasses the municipalities of Skive, Viborg, and Silkeborg. The ED treats patients referred by GPs and those who call 112, the Danish emergency number. On average, the ED handles 180 elderly patients per week. The ED initiated this study after observing that many elderly patients admitted to the ED could have been treated at home if the appropriate organizational structure had been established. In Denmark, GPs act as gatekeepers. Every Danish citizen is registered with a GP, who provide initial assessments and referring patients to hospitals or outpatient clinics as needed. They are self-employed, contracted with the government, and compensated per visit and for various services, as well as receiving a fixed annual amount for each registered patient. GPs also organize care during weekends and holidays, rotating shifts at regional out-of-hours centers, where they handle all patient calls. The GPs decide whether to offer phone consultation, directs visit to an out-of-hours GP, refers to a hospital or clinic, or arranges home visits. This study covers about 150 GPs across three municipalities. The municipalities are responsible for home nursing care, with municipal nurses performing planned tasks. Each municipality also has an acute care team composed of nurses specialized in admission avoidance (Fournaise et al. 2023). These teams are called upon by hospitals to continue patient treatment at home after initial hospital care, by GPs to visit and evaluate patients, or by municipal nurses to assist with advanced nursing tasks. In this project, the ED, three municipalities, and GPs have been actively involved at various organizational levels from the start. Table 1 illustrates how the various collaborators are involved, categorized according to the factors within the integrated implementation model. Table 1: The various collaborators involved in the project Organizations/collaborators ED 3 municipalities GPs* Leadership, steering committee Chief physician Head Nurse From each of the 3 municipalities: Head of Social and Health Services Two representatives from the GPs Leadership, task force The task force, consisting of 10 health-care professionals with varying types of knowledge and experience, acted as the action research group ED physician The manager of the hospital visitation The manager of the secretaries From each of the 3 municipalities: Head of the acute team and head of the municipality nursing care unit A GP Front-level staff ED physicians, hospital visitation nurses, secretaries Acute team nurses, municipality nurses GPs * The GPs are self-employed The cross-sectoral hospital-at-home treatment pathway implemented The hospital-at-home treatment pathway implemented in the first taking action phase is as follows. The physician (GP or out-of-hours medical service), who has seen the patient, calls the hospital visitation placed in the ED. The hospital visitation nurse checks the inclusion criteria and offers the referring physician a joint call, where the referring physician and the ED physician together do a medical assessment of the patient to decide whether the patient can be treated at home. Based on this dialogue, the ED physician, who takes over the treatment responsibility after the call, plans the treatment and calls the municipality acute team. At the first visit of the municipality acute team nurse, the patient gets oral and written information about the project and informed consent is obtained. If the patient is randomized to hospital-at-home treatment, the acute team nurse starts the treatment. The acute team, who is a group of experienced nurses specialized in providing acute care at home, can measure a patient’s vital signs, take ECG, bladder scan, and administer intravenous medications at home. If needed, the acute team takes blood samples and transports them to the hospital’s laboratory for processing. The acute team is available around the clock and visits patients whenever required under the treatment. The number of visits by the acute team or homecare nurse depends on the patient’s condition. During the treatment daily course, the acute team and the ED physician discuss the treatment either over the phone or virtually on an iPad, where the patient is also involved. If the physician wants to see the patient for a clinical examination or send the patient for an X-ray, he/she informs the acute team that the patient must undergo a short check-up in the ED. Here, the physician examines the patient him/herself and assesses whether the patient can continue to be in-home treated, or whether the patient must be admitted to the hospital due to deterioration of the condition. In case of an emergency at any time during the day, the patient can call the acute team who comes and checks on the patient. The acute team contacts the ED physician if needed to discuss the patient condition. If the patient is randomized to the control group, the patient will be admitted and receive the standard hospital treatment within the ED. Figure 3 illustrates the hospital-at-home treatment pathway. By treating patients at home, the ED, municipalities, and GPs form a collaborative network. The ED physician and the municipality acute team play key roles, with responsibilities divided into three stages: (1) input, (2) throughput, and (3) output (Asplin et al. 2003). The GP provides initial examinations during input, while the ED physician oversees treatment and coordinates with the acute team across all stages. The acute team manages care execution and delegates tasks to municipal nurses in the throughput stage. This collaboration requires communication and coordination across sectors but allows ED physicians and acute teams to work closely, “outsourcing” practical tasks from the hospital to the acute team, and bridges gaps between primary and secondary healthcare systems. Methods and implementation process The new hospital-at-home treatment model was planned through inter-organizational collaboration (Duvald 2021). Managers and the researcher introduced the acute team, ED physicians, secretaries, and hospital visitation staff to their individual tasks. During the planning phase, the task force developed with the researcher’s help written task descriptions for all employees. The task descriptions were adapted to each employee group but intertwined due to a sequential task design. At individual meetings with the researcher, they learned about the context, their specific work tasks, the entire task design, and the research material that the staff should use. Some were introduced for new tools such as a communication platform enabling virtual ward rounds between ED physicians and acute teams. During the initial implementation phase, the researcher was available for support. By late September 2020, the collaborators were ready to treat the first hospital-at-home patient. To follow and move the implementation process forwards and to address emerging issues, the researcher held online participating dialogue meetings every second month in the task force, consisting of ten practitioners and managers across organizations (Grundén et al. 2020). These meetings addressed practical challenges while reflecting on the hospital-at-home pathway implementation. Discussions covered broader topics, such as including more patients, and specific issues, like enabling acute teams to hire taxis for transporting blood samples or ensuring municipal nurses completed forms required for cost calculations. At the dialogue meetings, the task force addressed challenges in offering hospital-at-home treatment. Based on identified challenges, the researcher collected various data during the initial taking action phase (see Table 2), e.g., to identify inclusion barriers, a self-completion questionnaire was developed and distributed in the hospital visitation. Questions covered topics like the initial talk with referring physicians, collaboration with ED physicians, issues within the hospital visitation, and suggestions for improving inclusion. When doing action research, it is important to reflect on the process and collaboration in order to learn from it. Thus, before one dialogue meeting, each task force member filled out a self-completion questionnaire about the process, and the answers were discussed in plenum at the meeting. Steering committee meetings supplemented the task force meetings. Due to COVID-19, the chair of the steering committee, consisting of the ED chief physician and the head of social and health services from one municipality, held brief online status meetings weekly. Joined by the head of social and health services from the municipality, in which the pathway was implemented, the researcher and the project research adviser discussed adjustments. Every six months, the full steering committee met. A recurring issue was the low number of patients treated at home. Based on a task force suggestion, they decided to implement the pathway in another municipality during the initial taking action phase, requiring additional preparation, which affected the work within the task force. The two municipalities differed in several ways, e.g. the geographical distance to the hospital and acute team capabilities. The researcher acted as a link between the steering committee and the task force and facilitated the cycles of action and reflection as the project progressed. The project group, consisting of researchers, met to discuss data collection, and the researcher arranged some meetings with the practitioners to address document completion for the research evaluation. To get front-level staff perspectives on the new pathway, roles, implementation, and cross-sector collaboration, the researcher conducted individual interviews with acute team nurses and held two meetings with ED physicians (Kvale & Brinkmann 2009). During the first taking action phase, various data collection methods were used to meet objectives and information needs (see Table 2). The study draws on multiple data sources, including audiotaped meetings, interviews, questionnaires, meeting minutes, and documents. Table 2: overview of the various data sources and aim of the data collection Type of data Who Amount of data Aim/insights Audiotaped dialogue meetings Task force meetings 8 meeting Discussing and solving practical issues within the pathway and the implementation process Steering committee meetings 4 meetings Insights of the support to the task force and decisions made across the collaborators. Semi-structured interviews Acute team nurses 7 interviews with 10 nurses Insights of the nurses’ experiences with the new patient pathway, their role, collaboration with ED physicians, and implementation. Interviews conducted before implementing the pathway in another municipality. Patients and their relatives 4 patients and 3 relatives Insights of how the treatment model works and how the employees collaborate through first-hand experiences of the target group. Self-completion questionnaire Hospital visitation 14 fulfilled the questionnaire Insights of the benefits and challenges when including patients Task force members 11 members, all participated Insights of the members individually view on the process and collaboration. Meeting minutes Chair of the steering committee 48 morning meetings Insights of the process followed and discussed by the chair in a changing COVID-19 period. Emergency physicians 2 staff meetings Insights of the physicians’ experiences with the new patient pathway, their role, and collaboration with the acute team. Internal documents e.g. project description, work task descriptions, status mails, and newsletters Insights of the changes during the initial action research phase e.g. the continuously changes in the work task descriptions and the various challenges addressed in the process. The implementation process of the action research initiative took about two years. Figure 4 describes the timeline of the process and activities. Ethics The study was approved by the Ethical Committee, Central Denmark Region (no. 1-10-72-67-20), and all procedures followed were in accordance with Declaration of Helsinki. All patients offered hospital-at-home treatment were informed about the study aim and procedures by an acute team nurse prior to informed consent, which was obtained verbally and written. Employees, patients and relatives, surveyed or interviewed, received written information about the study and participated voluntarily, with all participants anonymized. Discussion of learning outcomes based on action research As action research has a dual aim: to address an issue and to contribute practical knowledge, we reflect on the action research process itself. Drawing on Coghlan and Shani’s framework (2014, 2018; Duvald 2021) that comprises four factors in assessing the quality of an action research initiative, we will discuss the learning outcomes of the first taking action phase within this action research project. The four factors comprise context, quality of relationship, quality of the action research process itself, and the outcomes. Furthermore, within these factors, we will reflect on the factors in the integrated implementation model, including the organizational and inter-organizational implementation behavior, the leadership, and front-level staff behavior (Winter and Nielsen 2008). Context Coghlan and Shani’s framework emphasizes understanding socio-political, cultural, and structural forces as drivers or inhibitors of organizational change. In this case, the drivers for change in the Danish health system, outline in the introduction, led the three collaborators design and implement a hospital-at-home pathway to improve care for elderly acute ill patients while addressing demographic challenges. Quality of relationships The quality of relationships comprises both how the action research is research with people, thus the relationship between the researcher and the practitioner, but also the relationship between the various practitioners (Shani and Coghlan 2021). Relationship between the researcher and practitioners Given the involving nature of action research, the researcher worked closely with the practitioners from the different organizations (and organizational levels within the organizations) in a process of addressing the need for hospital-at-home treatment of the elderly and knowledge generation in the local context of treatment of elderly acute ill patients. The aim was to gather the various experiences about the implementation of the hospital-at-home treatment pathway. In the taking action phase, researchers and practitioners collaboratively tested actions and adapted the hospital-at-home model to practical reality. A learning environment was fostered where experiences, challenges, and successes were openly shared. Continuous evaluation involved the researcher engaging with employees at the hospital and in the municipalities in daily tasks and formal staff meetings to gather insights. As one acute team nurse noted, the researcher’s support was invaluable: “ It has been a great support to have (the researcher) , meaning you have had the opportunity to call and ask. (…) Because we learn along the way. But I think we have been helped quite well by the fact that (the researcher) was out here so frequently at the beginning as well as called us. ” If the employees came up with ideas for process improvement, such as audits to review patient processes (described further later), they were implemented. Researchers and practitioners also co-developed and tested a micro costing tool for the health economic evaluation. Designed to meet research standards and fit nurses’ daily routines, the tool benefited from shared ownership. Nurses suggested solutions, like notifying the researcher and nursing team manager via email, when a patient was included, to support accurate form completion. If data were missing, the researcher could follow up with the specific team. The organizational and inter-organizational relationships and behavior The treatment model and implementation process included three different types of organizations with different interests: a hospital, 3 municipalities, and about 150 GPs. To make the various stakeholders collaborate about the new pathway across organizations, a small-scale collaborative community was established in the planning phase as the underlying project organization (Duvald 2021). A collaborative community brings together multiple stakeholders to work collectively to achieve a common outcome, solve a shared challenge, and leverage collective opportunities in an environment of trust, respect, and openness - without the use of hierarchy as the primary mechanism of control and coordination. The collaborative community was established to address and renegotiate challenges across organizations. Steering committee meetings identified and resolved issues in joint dialogue such as municipalities declining hospital-at-home patients due to capacity, ED physicians adapting to treat patients they did not physically assessed, and changes in GP behavior post-COVID-19. The project’s inter-organizational collaboration is supported by the ‘cluster collaboration’, a biannual forum, where hospital, municipality, and Prehospital directors as well as GP representatives are updated on project progress. The leadership Leaders from the organizations’ various levels participated in either the steering committee or task force, showing strong commitment to the project - even though several of them have been replaced during the project period. One example is the chair of the steering committee. The meeting frequency has been high with weekly morning meetings. So high, in fact, that after nine months one of the leaders remarked that he had never experienced such frequent meetings in a project. During the first taking action phase, the task force’s collaboration shifted, when the steering committee decided to test the pathway in one municipality. Through active participation, this municipality took a leading role, while the others became sparring partners in discussions and evaluations. As one member noted in a written reflection four months in, the task force’s role was: that everyone in the group contributes with ideas and proposed solutions; that everyone plays the process well . Thus, they expected everyone to contribute ideas and solutions and remain committed across organizations. The role of leadership in transformation is often influenced by information asymmetry between leaders and front-level staff (Winter and Nielsen 2008). In this project, information flow between task force and steering committee members within the municipalities varied. However, the researcher acted as a bridge between employees, task force, and steering committee, by conveying employee challenges, task force questions, and management decisions. If needed, the researcher facilitated connections such as inviting the chair to a task force meeting. The front-level staff relationships and behavior When implementing the hospital-at-home pathway, the ED physicians and the acute team nurses got new work tasks. The employee’s behavior and performance of these tasks influenced the implementation of the treatment model. The ED physicians wanted to maintain their tasks similar to their usual routine to minimize resistance, which could reduce the number of patients offered hospital-at-home treatment. As one physician noted: “ Could it be made easier in terms of documentation? If the instructions can be shaved down to a single page with bullet points, so that you don’t have to sit and fight with 4 pages, of which page 3 may be missing - it’s just a built-in resistance ”. Thus, the tasks and task description were adjusted continuously, e.g. initially the physicians were asked to write journal notes, but they requested dictation and transcription by secretaries instead. This adjustment ensured acute team nurses received written tasks promptly, a requirement for cross-sector collaboration. Additionally, ED nurses now handle ordering samples and tests, further easing physicians’ workload. The ED physicians, who are treatment responsible, had to trust referral physician’s assessments and the acute team nurses rather than directly evaluating patients, which require time to build confidence. To support this and to ensure quality, a physician suggested evaluating patient cases through audits. The ED management supported the idea. Now, two ED physicians independently review each case to identify delay or deficiencies. Findings are shared with ED physicians, municipality acute teams, the task force, and the steering committee to ensure quality and trust in the process. In the pathway, the municipality acute team handles home treatment. Most of them find it meaningful and challenging compared to routine tasks, though they were surprised by its complexity. To manage the many tasks, they developed various strategies. One management strategy was working in pairs, where one performed tasks, while the other followed the task description and ensured all steps were completed. This approach also helped them learn and support each other, especially with time-consuming research-related tasks. Another strategy involved dividing tasks into clinical tasks, research tasks, and collaboration with physicians. One nurse explained: I divide it into three blocks. Because I see it as a completely normal assessment (…) then there is a block called contact with the physician - it just happens to be an ED physician, and then there is all the project-related stuff: function test, survey, consent, registration, submission of blood samples. All those things - and that is a block in itself (…) And when I can just... ticking of the tasks from the to-do list (the work task description) , then I don’t think it’s confusing. ” Others felt overwhelmed, especially when alone on duty, and used prevention strategies like avoiding tasks on busy weekends. One nurse said: ”… I do not want to stress about this, and I do not want to drive around with a guilty conscience and a stone in my stomach. Thus, I decided that every time I have a weekend shift that is too hectic, like the last one, then I will simply say, I cannot do it. (…) I support this project, but it cannot work in our weekends. I do not want to walk around feeling sick - having stomach pain. That every time the phone rings, you think, as long as it is not a hospital-at-home patient, you simply cannot do that. ”. The nurses agreed that treating patients at home was a learning-by-doing process, requiring ongoing problem solving, and access to support from the researcher, when needed. To support the nurses, the hospital at home treatment pathway was often discussed at local staff meetings, in which the researcher also participated. One thing that was resolved after such a meeting was that the researcher found a solution to a parking challenge at the hospital, when the nurses had to come in to deliver blood samples and pick up medicine. The nurses also found the interviews useful in terms of talking about the benefits and challenges of the pathway. The collaboration between hospital and municipal healthcare professionals in the hospital-at-home patient pathway is new and built on trust. Written work task descriptions and agreements across organizations have supported this, with adjustments if needed. For example, it was clarified that acute team nurses have the authority to recommend hospitalization, if necessary, as they are physically with the patient. This addition, requested by the nurses, boosted the nurses’ confidence in their tasks and collaboration with the ED physicians. The healthcare professionals’ work task descriptions are interdependent in the sequential pathway, which caused challenges during the start-up phase. Frustrations arose when some employees deviated from their tasks, often due to a lack of understanding of others’ roles. For example, ED physicians needed to know that an acute team nurse’s initial patient visit could take hours, affecting patient inclusion timing. Adjustments were also needed, such as requiring the acute team to notify the hospital visitation in advance, if they lacked resources for hospital-at-home treatment, preventing wasted efforts and unnecessary patient delays. Clinicians’ frustrations from miscommunication in interdisciplinary teams have been reported (Chua et al. 2022). In this project, misunderstandings arose between ED physicians and nurses, such as acute team nurses needing immediate help during calls, otherwise they must drive to another patient, who may live half an hour away, or scheduling ward rounds. In these situations, the researcher acted as a translator and broker to bridge these gaps. Efforts included municipality nurses attending staff meetings with ED physicians and hospital visitation nurses, and an ED physician shadowing the acute team to better understand their tasks. Quality of the action research process itself (learning cycles) Action research involves multiple cycles of action and inquiry over time. Some of them are short-term cycles, while others are long-term cycles. The first taking action phase was a learning cycle itself, planned by the task force based on workshop ideas from healthcare professionals. The patient pathway was tested, implemented, and evaluated by employees, the task force, and the steering committee, with many small adjustments made. Though a collaborative learning process, this phase focused on testing and optimizing the pathway through rapid cycle experiments, refining it on a small scale before proceeding to a large-scale implementation of the pathway in all municipalities. Ultimately, the first taking action phase included three larger learning cycles, as shown in Figure 5. Within the process, the steering committee decided to test the pathway within another municipality. As a part of the expansion from one municipality to another, the experiences from implementing the pathway in the first municipality were used e.g. all the adjustments made in the work tasks descriptions. Moreover, firsthand experiences from the acute team were shared with the other acute team. The acute teams from the various municipalities do not use to share knowledge; however, two nurses were invited to take part in the researchers’ introduction meeting, which provided the opportunity to initiate a new exchange of experiences across acute teams. However, this municipality was different from the first in several ways: the size of the acute team, the competences within the acute team, the location of the acute team, the distance to the hospital, etc. Thus, implementing the pathway in the new municipality required planning, testing, and finding solutions to new challenges. Moreover, due to the upcoming evaluation phase within the action research project including an RCT-study, the pathway for and the cross-sectoral collaboration for the patients in the control group had to plan, test, and evaluate as well. Another aim was to adjust the organization to practice, and as expected, the implementation did not happen all at once, but as ongoing processes with incremental adjustments. It was found that the employees are good at describing things that did not work and thus it was possible to adjust the work task descriptions. Many minor things were adjusted, and the layout of the descriptions were adjusted. Outcomes The outcome of this phase was the implementation of a hospital-at-home treatment pathway. One of the aims of the first taking action phase was to test the organization of the pathway by implementing it in one municipality, and the overall judgement was that the hospital-at-home organization works; elderly patients can be treated in their homes by the acute team under supervision of the ED physician. Another outcome is the knowledge about challenges and advantages in the implementation process, which has been created in a joint dialogue across organizations within the project. Lessons learned by going through a slow transition state Coghlan and Shani (2018, p. 80) describe the transition state between the present and future as challenging, as the old has ended but the new is not yet realized. The COVID-19 situation prolonged this ‘liminality phase’, where adjustments to the new way of working went slow. Liminality, as defined by Turner (1967), refers to disorientation experienced during a rite of passage, when participants are between their pre-ritual status and the status they will get, when the rite is complete. In this project, the taking action phase was an in-between period, which frustrated the employees; the pathway was implemented, and the employees adapted a new way of working. At the same time, the pathway was being tested to determine its long-term viability. One inclusion criterion required the referral physician to see the patient before admission to the hospital-at-home pathway. However, during COVID-19, GPs avoided seeing patients with fever and coughs – key symptoms the pathway was designed to treat – resulting in the traditional gatekeeper system being set aside. This environmental change impacted implementation, leading to fewer hospital-at-home admissions than expected and extending the planned three-month phase to two years. Task force members highlighted the prolonged timeline as surprising, and the acute team nurses discussed benefits and challenges with the slow patient inclusion. It hindered learning the workflow, as each case felt like starting over. This complicated the cross-sector collaboration too due to confusion about roles and tasks, leading to frequent discussions. However, the slower pace also allowed time to refine processes, such as ensuring two nurses were present at the first patient visit. Testing of certain pathway elements, like online ward rounds and blood test transportation, also faced delays. Due to the slow inclusion of patients, the steering committee decided to implement the pathway in a second municipality earlier than planned, adding more learning cycles due to differences between the municipalities. Despite this, satisfaction with the number of patients included was noted at meetings, given the challenges of implementing during COVID-19. Conclusion This study contributes to the growing body of knowledge on the implementation of hospital-at-home models, focusing on the complexities and opportunities of cross-sectoral collaboration. By employing an action research approach, the study not only documented the implementation process but also actively engaged healthcare practitioners in co-creating solutions to organizational challenges. The findings demonstrate that trust, communication, and iterative adjustments are essential for fostering collaboration between hospitals, municipalities, and GPs. These factors were critical to aligning diverse organizational practices and ensuring the successful delivery of hospital-at-home treatment. The study highlights the importance of integrating front-level staff into the implementation process and adapting workflows to reduce resistance and enhance feasibility. Tools such as structured work task descriptions and collaborative reflective meetings proved effective in addressing barriers. By embedding action research within the implementation process, this study facilitated real-time adjustments and generated actionable knowledge. This approach ensured that the organizational model was tailored to the unique needs of the participating stakeholders while maintaining scientific rigor. The findings underscore the potential of hospital-at-home models to address demographic and healthcare challenges, offering a patient-centered alternative to traditional hospitalization. Future research should build on these insights to explore long-term outcomes and scalability in diverse healthcare contexts. Statements and declarations Ethical Approval The study was approved by the Ethical Committee, Central Denmark Region (no. 1-10-72-67-20), and all procedures followed were in accordance with Declaration of Helsinki. All patients offered hospital-at-home treatment were informed about the study aim and procedures by an acute team nurse prior to informed consent, which was obtained verbally and written. Employees, patients and relatives, surveyed or interviewed, received written information about the study and participated voluntarily, with all participants anonymized. Informed Consent to Participate All patients offered hospital-at-home treatment were informed about the study aim and procedures by an acute team nurse prior to informed consent, which was obtained verbally and written. Employees, patients and relatives, surveyed or interviewed, received written information about the study and participated voluntarily, with all participants anonymized. Funding statement The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Novo Nordisk Foundation [grant number NNF21OC0070180] and the Quality and Training Committee, Central Denmark Region [grant number 1-30-72-29-19]. Trial registration number Clinical trial number: not applicable. This paper investigates the implementation of a cross-sectoral admission avoidance hospital-at-home model. In other papers, we investigate the clinical outcomes, thus we have a clinical trial number, however it is not relevant to this paper about implementation. References Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA Jr (2003) A conceptual model of emergency department crowding. Annals of Emergency Medicine 42(2):173-180 Bardach E (1977) The implementation game. Cambridge, MA: MIT Press. Bradbury H, Lifvergren S (2016) Action research healthcare: focus on patients, improve quality, drive down costs. Healthcare management forum 29(6):269-274 Brody AA, Arbaje AI, DeCherrie LV, Federman AD, Leff B, Siu AL (2019) Starting up a hospital at home program: facilitators and barriers to implementation. Journal of the American Geriatrics Society 67(3):588-595 Bøllingtoft A, Donaldson L, Huber GP, Håkonsson DD, Snow C (Eds.) (2012) Collaborative communities of firms: Purpose, process, and design. New York, NY: Springer Caplan GA, Sulaiman NS, Mangin DA, Aimonino RN, Wilson AD, Barclay L (2012) A meta‐analysis of “hospital in the home”. Medical Journal of Australia, 197(9):512-519 Chua CMS, Ko SQ, Lai YF, Lim YW, Shorey S (2022) Perceptions of hospital-at-home among stakeholders: a meta-synthesis. Journal of general internal medicine 37(3):637-50 Coghlan D (2019) Doing action research in your own organization (5th ed.). London: SAGE Publications Coghlan D, Shani AB (Rami) (2014) Creating action research quality in organization development: Rigorous, reflective and relevant. Systemic Practice and Action Research 27:523-536 Coghlan D, Shani AB (Rami) (2018) Conducting action research for business and management students. Los Angeles, CA: SAGE Publications Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D (2003) Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulnerability with age. Journal of the American Geriatrics Society 51(4):451-458 Creditor MC (1993) Hazards of hospitalization of the elderly. Annals of Internal Medicine 118(3):219-223 Duvald I (2021) Using Action research and organization design to plan in-home hospital treatment. In: (Rami) Shani AB, Noumair DA (ed) Research in Organizational Change and Development 29. Emerald Publishing Limited, Leeds, pp 111-142 Elmore RF (1982) Backward Mapping: Implementation Research and Policy Decisions: In: Williams W et al. Studying Implementation. Chatman: Chatman House Publishes, Inc. Fournaise A, Andersen-Ranberg K, Lauridsen JT, Espersen K, Gudex C, Bech M (2023) Conceptual framework for acute community health care services - Illustrated by assessing the development of services in Denmark. Social Science & Medicine (324) 115857 Gray B (1985) Conditions facilitating interorganizational collaboration. Human Relations 38(10):911-936 Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O (2004) Diffusion of innovations in service organizations: systematic review and recommendations. The milbank quarterly 82(4):581-629 Grundén K, Svensson A, Forsman B, Karlsson C (2020) Dialogue meetings as an arena for collaboration and reflection among researchers and practitioners in a pre-study of a welfare technology testbed. International Journal of Engineering Management and Economics 14(8):629-634 Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR (1999) A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine 340(9):669-676 Kvale S, Brinkmann S (2009) Interviews: learning the craft of qualitative research interviewing, 2nd edn. Sage, Los Angeles Leff B (2009) Defining and disseminating the hospital-at-home model. Canadian Medical Association Journal 180(2):156-157 Leff B, DeCherrie LV, Montalto M, Levine DM (2022) A research agenda for hospital at home. Journal of the American Geriatrics Society 70(4):1060-1069 Leong MQ, Lim CW, Lai YF (2021) Comparison of Hospital-at-Home models: a systematic review of reviews. BMJ Open 11:e043285 Lipsky M (1980). Street-level Bureaucrazy. New York: Russel Sage Foundation MazManian DA, Sabatier PA (1981) Effective Policy Implementation. Lexington: Lexington Books Nielsen CP (2021) Implementation. In: Jørgensen P, Kjølby M, Jensen JW (ed) Research, Quality and Clinical Practice. Copenhagen: Munksgaard (in Danish) Nielsen CP, Fredens M, Ledderer L (2022) Implementation of Complex interventions. In: Petersen KS, Maindal HT, Ledderer L, Overgaard C (ed) Complex Interventions - Development, Test, Evaluation and Implementation. Aalborg: Aalborg universitetsforlag (in Danish) Nilsen P, Ståhl C, Roback K, Cairney P (2013) Never the twain shall meet? - a comparison of implementation science and policy implementation research. Implementation science 8:1-12 Oksuzyan A, Höhn A, Pedersen JK, Rau R, Lindahl-Jacobsen R, Christensen K (2020) Preparing for the future: The changing demographic composition of hospital patients in Denmark between 2013 and 2050. PLoS One 15(9) e0238912 Pressman JL, Wildawsky A (1973) Implementation. Berkeley: University of California Press Rothman RD, Delaney CP, Heaton BM, Hohman JA (2024) Early experience and lessons following the implementation of a Hospital‐at‐Home program. Journal of Hospital Medicine Shani AB (Rami), Coghlan D (2021) Collaborative Inquiry for Organization Development and Change. Edward Elgar Shani AB, Eberhardt BJ (1987) Parallel organization in a health care institution: An exploratory action research study. Group & Organization Studies 12(2):147-173 Shepperd S, Iliffe S, Doll HA, Clarke MJ, Kalra L, Wilson AD, Gonçalves-Bradley DC (2016) Admission avoidance hospital at home (review). Cochrane Database of Systematic Reviews 9(9) Strausbaugh LS (2001) Emerging health care-associated infections in the geriatric population. Emerging Infectious Diseases 7(2):268-271 The national association of municipalities (2013) Effective municipal prevention - Focusing on prevention of admissions and readmissions. (In Danish) Turner V (1967) Betwixt and Between: The Liminal Period in Rites de Passage. In The Forest of Symbols. Ithaca, NY: Cornell University Press Vale JS, Franco AI, Oliveira CV, Ara´ujo I, Sousa D (2019) Hospital at home: An overview of literature. Home Health Care Management & Practice:1-6 Wallis JA, Shepperd S, Makela P, Han JX, Tripp EM, Gearon E et al (2024) Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis. Cochrane Database of Systematic Reviews (3) Winter SC (2006) Implementation. In: Peters BG, Pierre J (ed) Handbook of Public Policy. Sage Publication Ltd. Winter SC, Nielsen VL (2008) Implementation of politics. Hans Reitzels Forlag Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":24517,"visible":true,"origin":"","legend":"\u003cp\u003eThe integrated implementation model, inspired by Winter and Nielsen 2008\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7758401/v1/c4c4c602205b45f957be5946.png"},{"id":93797695,"identity":"92f06048-4f97-4010-9acf-5188cae94450","added_by":"auto","created_at":"2025-10-17 16:01:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":88624,"visible":true,"origin":"","legend":"\u003cp\u003eDescription of how the project follows Coghlan and Shani’s framework\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7758401/v1/9a678780afbbf59bb3162445.png"},{"id":93796801,"identity":"c1febad5-87d9-493a-8f1a-56cc98af8310","added_by":"auto","created_at":"2025-10-17 15:53:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":20407,"visible":true,"origin":"","legend":"\u003cp\u003eThe hospital-at-home treatment pathway\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7758401/v1/99f6c6232682a31670f52d0d.png"},{"id":93796697,"identity":"c8501110-3890-45b6-b53d-32f4a7ef2eaa","added_by":"auto","created_at":"2025-10-17 15:53:40","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":266046,"visible":true,"origin":"","legend":"\u003cp\u003eTimeline illustrating the various steps and data collections in the taking action phase\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7758401/v1/5187bdd9e32cf6ca4f0447d9.png"},{"id":93796648,"identity":"ce1a4e1e-0852-446f-8ace-64875cd10cf2","added_by":"auto","created_at":"2025-10-17 15:53:38","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":15578,"visible":true,"origin":"","legend":"\u003cp\u003eThe three leaning cycles within the first taking action phase\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7758401/v1/ca9b2afa3706212803a98098.png"},{"id":93797698,"identity":"735405bb-82b1-4e56-8e7f-d7706bb7748f","added_by":"auto","created_at":"2025-10-17 16:01:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":960443,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7758401/v1/62fd2189-1f85-4b9e-b0b0-d4fc89a22a1c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementing cross-sector hospital-at-home treatment: challenges, opportunities and action research insights","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAs healthcare systems grapple with the pressures of an aging population, innovative solutions are needed to address the rising demand for acute care. Hospital-at-home models have emerged as a promising alternative, offering hospital-level treatment within the patient’s home. This approach minimizes risks associated with hospitalization, such as infections and functional decline. However, implementing such models requires overcoming significant organizational challenges. This paper examines these complexities through an action research study, shedding light on the processes, opportunities, and obstacles encountered in establishing a cross-sectoral admission avoidance hospital-at-home model in Denmark.\u003c/p\u003e\n\u003cp\u003eHealthcare systems today face great challenges, e.g., the demographic challenge of a fast-growing ageing population. In Denmark, the total number of hospital days per year is expected to increase by 42% between 2013 and 2050, from 4.66 to 6.72 million days, and the largest change is expected to occur for the population aged 70+ (Oksuzyan et al. 2020). However, hospitalization is not always the best solution for elderly patients. Emergency admissions can disrupt daily routines, increase the risk of infection and delirium, and lead to physical and mental decline, which may take a long time to recover (Covinsky et al. 2003; Creditor 1993; Inouye et al. 1999; Strausbaugh 2001). Furthermore, many elderly acute medical patients are admitted for a short period in order to undergo comparatively uncomplicated treatment, which in many cases could have been avoided, if alternatives had been developed (The national association of municipalities 2013).\u003c/p\u003e\n\u003cp\u003eFinding alternatives to hospitalization is increasingly necessary. One such alternative, developed in many countries around the world, is the hospital-at-home model, which is rapidly growing (Sheppard et al. 2016). In this model, healthcare professionals provide hospital-level care in patients’ homes for a limited period, treating conditions that would typically require acute hospital inpatient care. These services are often aimed at elderly medical patients and can be organized in various ways. Two main types of hospital-at-home models have been identified. In the early-supported-discharge-model, patients are discharged early and continue treatment in home, while in the admission-avoidance-model patients avoid physical contact with the hospital and are directly treated at home based on general practitioner referrals (Leong et al. 2021). These models vary in terms of illnesses treated, patient acuity, admission sources, treatment team composition, and the level of physician and nursing care provided (Leff 2009; Shepperd et al. 2016; Vale et al. 2019).\u003c/p\u003e\n\u003cp\u003ePrevious studies about hospital-at-home models have demonstrated significant reductions in mortality, readmission rates, and costs, along with better patient and caregiver satisfaction compared to in-hospital treatment (Caplan et al. 2012). Although hospital-at-home models have several strengths, their inherent complexity presents challenges for implementation (Leong et al. 2021).\u003c/p\u003e\n\u003cp\u003eThe implementation of hospital-at-home models has been explored in previous research. For instance, Brody et al. (2019) conducted focus groups to analyze retrospectively and recall the implementation process, offering insights into the challenges and successes encountered. Rothman et al. (2024) examined the process of building and implementing a hospital-at-home model, providing a comprehensive guide on the necessary steps, from initial planning and resource allocation to the integration of clinical services and patient care protocols. Wallis et al. (2024) went through 52 qualitative studies exploring the implementation of hospital-at-home services and found four themes: development of stakeholder relationships and systems prior to implementation, requirements for safe and effective implementation, acceptability and caregiver impacts, and sustainability of services. Still, more research about implementation of hospital-at-home treatment is needed (Leff et al. 2022).\u003c/p\u003e\n\u003cp\u003eIn this paper, we will report on a study that investigates an admission avoidance hospital-at-home treatment pathway and how it was implemented. In 2018, a hospital emergency department (ED), three municipalities, and general practitioners (GPs) decided to collaborate with the aim of reorganizing the treatment of elderly patients in order to create a hospital-at-home pathway. Through the collaboration, they wanted to create a better option for the elderly acute ill patients and at the same time handle the demographic challenge. Collaboration is a process in which parties with a stake in a problem actively seek a mutually determined solution. It involves overcoming many barriers, particularly when it spans various organizations (Bøllingtoft et al. 2012). Thus, implementing a cross-sectoral admission avoidance hospital-at-home treatment model is expected to be challenging, when three healthcare organizations collaborate. However, collaboration is essential in situations where a shared goal can only be achieved by a group of actors, each contributing complementary efforts to a larger system in a coordinated manner (Gray 1985). This is crucial in reorganizing care of elderly patients, who need treatment from multiple professions across different organizational units and sectors. Successful collaboration is key to co-creating a new organizational model for hospital-at-home treatment, as it requires employees to adapt practices and work together effectively (Duvald 2021).\u003c/p\u003e\n\u003cp\u003eTo facilitate and follow the process with developing and implementing the new organization for hospital-at-home treatment in a collaboration with multiple different stakeholders, an action research approach was chosen. As Bradbury and Lifvergren (2016) note: action research in healthcare shifts the focus from traditional expertise to distributing authority among stakeholders across multiple complex systems, and engaging participants in reflecting on their experiences.\u0026nbsp;This method is suitable for involving all occupational groups in patient treatment to collaboratively discuss and negotiate the best course of action.\u003c/p\u003e\n\u003cp\u003eUsing an action research approach, the study captures iterative learning cycles that facilitated the co-creation and refinement of the hospital-at-home model. The aim is to generate actionable insights into the processes and dynamics of implementation in a multi-organizational healthcare setting, emphasizing the roles of inter-organizational collaboration, leadership, and frontline staff. These findings offer practical guidance for improving the design and execution of similar initiatives in complex healthcare environments. The following section frames implementation as a process, drawing on policy implementation theory to analyze the development and adoption of the hospital-at-home model.\u003c/p\u003e"},{"header":"Theoretical approach: implementation as a process","content":"\u003cp\u003eWithin health research, implementation science is often used as the primary theoretical lens to understand implementation of new activities in health care organizations. However, implantation science often focuses on the perspective of the healthcare professionals’ perceptions and experiences and leave out other perspectives when understanding implementation processes (Nilsen 2013; Nielsen 2021). We therefore turn to policy implementation theory that allows for a broader focus on multiple types of actors and organizational perspectives.\u003c/p\u003e\n\u003cp\u003eThe implementation of new policies and interventions within the public sector has been studied within social sciences since the 1970’ties, where the first studies reported on the difficulties of making planned changes happen in practice (Pressman and Wildawsky 1973; Bardach 1977). The early development of theory focused on top-down and bottom-up perspectives respectively (Winter 2006). The first with a focus on exploring how policy development, law, and hierarchical implementation structures provide opportunities and barriers for implementing planned changes (e.g. Mazmanian and Sabatier 1981). The second with a focus on studying how the front-level staff often play a crucial role in making decisions on how changes can be implemented in practice (Lipsky 1980; Elmore 1982). Today, the two perspectives are still predominant perspectives in the theoretical understanding of implementation, but over time, the perspectives have been synthesized into models that recognize the co-existence of both top-down and bottom-up perspectives (Greenhalgh 2004; Winter 2006; Nielsen et al. 2022). One such integrated implementation model building on various theories has been developed by Winter (Winter 2006; Winter and Nielsen 2008). Figure 1 shows the various elements in the model.\u003c/p\u003e\n\u003cp\u003eThis model is based on a process perspective; that the implementation of an intervention consists of different phases, including designing, implementing, and a result. It can be used to analyze the implementation process and why the implementation may succeed or fail.\u003c/p\u003e\n\u003cp\u003eThe model illustrates how the initial decisions concerning design of a change, in this case the decision on establishing a cross-sectoral admission avoidance hospital-at-home model, sets a framework for the implementation process, and thus partly defines the background for potential barriers and opportunities in the implementation process. Thus, design is about what preceded the implementation, and what implication this has for the implementation process. The design of the hospital-at-home model is described elsewhere (Duvald 2021). In this paper, in the analysis we will zoom in on the particular part of the integrated implementation model that describes the implementation process. Based on prior studies of implementation processes, the model identifies four elements, which influence the output and outcome of the process (Winter and Nielsen 2008).\u003c/p\u003e\n\u003cp\u003eOrganizational and inter-organizational implementation behavior: The behaviors of organizations are key to results of an implementation process. Often implementation processes include different authorities and organizations with different interests. They typically have opportunities to promote or distort the intentions behind the interventions, and the behavior often constitutes a complex interplay between these interests.\u003c/p\u003e\n\u003cp\u003eLeadership has a significance when organizational objectives are transformed into behavior among front-level staff. The role of leadership for transformation is typically affected by the potential information asymmetry between leaders and front-level staff, and the instruments that are used by leaders to assure the transformation.\u003c/p\u003e\n\u003cp\u003eFront-level staff are assumed to play an autonomous role in relation to the output and outcome of the implementation process. The staff often make a substantial discretion when it comes to the decision on how to deliver public services to the target group of the intervention and is therefore often referred to as ‘the real decision makers’. There may be differences between employees depending on their sense of ownership of the intervention, their perceived workload, their attitudes and knowledge, and the situation.\u003c/p\u003e\n\u003cp\u003eThe target group behavior is considered crucial for the output and outcome of the implementation process. The target group often interacts with the front-level staff in joint-production of the services delivered and thus has an impact on the results of an implementation process.\u003c/p\u003e\n\u003cp\u003eIn the model, performance refers to the changed behavior among the actors in the implementation process. Finally, the environment, e.g. the time or political changes, including any changes that may occur in the environment, often influences the implementation process.\u003c/p\u003e\n\u003cp\u003eIn the analysis of the implementation process, we have decided to focus on the interplay between the organizational and inter-organizational implementation behavior, the leadership, and front-level staff behavior. In this project, it is a decision of physicians, if the patient is offered treatment in their own home. The patients as the target group prefer to be and accept hospital-at-home treatment.\u003c/p\u003e\n\u003cp\u003eTo closely follow and facilitate the implementation process, an action research approach was chosen, enabling collaborative problem-solving and iterative learning. Furthermore, this approach creates the opportunity to implement the pathway directly, because the healthcare professionals themselves test whether the pathway works and makes sense in their practice.\u003c/p\u003e"},{"header":"Methodology: Action research","content":"\u003cp\u003eAction research is a philosophical approach, with a methodological framework where researchers and practitioners collaborate closely with two objectives, to solve a problem and at the same time contribute with new knowledge (Shani and Coghlan 2021). \u0026nbsp; It aims at generating practical knowledge for practice that is also robust for scholars. As research that is taking place concurrent with action it consists of iterative cycles of action and reflection, larger and smaller, consisting of four basic steps or phases: constructing, planning action, taking action, and evaluating action. In the constructing phase, the focus is on mapping the past and present in order to be able to contribute to changing the future. In the planning action phase, the actors move from what they are doing now to what they believe should be doing in the future. In the taking action phase, the concrete actions that researchers and practitioners have come up with, which they would like to test in practice together, are carried out collaboratively and implemented. In the evaluating action phase, the final evaluation of the taking action phase and the process of changing practice takes place, including both intended and unintended outcomes (Coghlan 2019). In this paper, we will focus on the taking action phase, in which the hospital-at-home treatment pathway was implemented.\u003c/p\u003e\n\u003cp\u003eAction is central because the starting point for learning, development, and change is based on joint experimentation with testing new actions created through joint dialogue aimed at addressing issues and solving problems (Coghlan 2019). Action is created by and leads to dialogue and critical reflection, and on that basis, new insights and knowledge are created. When the changes are initiated and tested over time, the implementation takes place at the same time that participants and researchers develop, test, and adjust the new way of working. Thus, as action research is understood to be taking place in the present tense on live issues, implementation is a key process as addressing how the issue unfolds and learning and practical is generated.\u003c/p\u003e\n\u003cp\u003eWithin this experimental implementation process, the action researcher works closely with the practitioners and is the facilitator of conversation and of emergent learning/knowledge cogeneration (Shani and Eberhardt 1987). The practitioners contribute their experience and knowledge of their own practices, while the researcher contributes their skills in facilitation, methodology, analysis, and process oversight. Through the cyclical process of action research, reflection and learning are initiated, leading to the creation of new knowledge (Coghlan 2019).\u003c/p\u003e\n\u003cp\u003eCoghlan and Shani (2014, 2018) offer a framework of four factors to enable the quality of an action research initiative to be assessed. First, it needs to be demonstrated how socio-political, commercial and cultural forces are driving the need for the issues to be addressed and for knowledge to be generated. Second, the quality of collaborative relationships between participants in the action and the research is paramount. \u0026nbsp;Third, the quality of how action and inquiry progress together through cycles of action and reflection as the project is progressing. Fourth, demonstration of the dual outcomes of a) improved organizational practice, and b) the creation of practical knowledge through the action and inquiry.\u003c/p\u003e\n\u003cp\u003eThe following case provides a detailed account of how the hospital-at-home model was developed and implemented through action research, offering practical insights into the complexities of cross-sectoral collaboration in real-world settings.\u003c/p\u003e\n\u003cp\u003eDescription of the case\u003c/p\u003e\n\u003cp\u003eThe first taking action phase\u003c/p\u003e\n\u003cp\u003eThe action research project was initiated in February 2018 and is still ongoing. This paper describes the results from the first taking action phase, in which the hospital-at-home model was tested and implemented, while the previous phases in the project, the constructing and planning action phase, will briefly be summarized, but are described in detail elsewhere (Duvald 2021). Figure 2 illustrates the various phases in the project following Coghlan and Shani\u0026rsquo;s framework.\u003c/p\u003e\n\u003cp\u003eAn anthropologist, who has been studying organization design challenges within the emergency health care field, and has been affiliated with the ED since 2014, was asked to facilitate the co-creation process as project manager. She is the primary researcher at the project. Thus, having access to both information and individuals that would most likely not be available to an outside researcher. The first author of this paper is the project manager but named the researcher in the rest of the paper.\u003c/p\u003e\n\u003cp\u003eIn the construction phase, an inter-organizational steering committee and a task force were established. Moreover, the researcher explored the existing collaboration between the ED, municipalities, and GPs though an extensive fieldwork. The results of the fieldwork were presented for the steering committee and task force to create a common and a holistic picture and understanding of existing collaboration (the existing situation and operating procedures) among the practitioners and make the collaborators aware of the dependence on each other and thus qualify the planning of the new way of collaboration. The joint (practitioners and researcher) discussions about where to improve, and how to design the hospital-at-home treatment pathway.\u003c/p\u003e\n\u003cp\u003eThe planning phase consisted of workshops and task force dialogue meetings. ED physicians and nurses, municipality nurses, GPs, and an EMS service physician were invited to participate in workshops. Based on their experiences, they generated ideas about and explored collaborative how to design the hospital-at-home pathway. The task force continued to work with the employees\u0026rsquo; ideas and planned, with input from the steering committee, how the patient pathway and cross-sectorial collaboration should be organized, so that it could be tested and implemented in one municipality in the first taking action phase.\u003c/p\u003e\n\u003cp\u003eThe taking action phase was divided in two phases in the project. This paper describes the results from the first taking action phase, in which the hospital-at-home model was tested and implemented in two municipalities, both the facilitated change (the organizational design of a hospital-at-home treatment pathway), and the learnings by studying the co-creation and implementation process from an outsider-perspective. In the second taking action phase, the hospital-at-home model will be implemented in the last municipality. When the model is offered in all three municipalities, data for the final evaluation will be collected.\u003c/p\u003e\n\u003cp\u003eThe aims of the first taking action phase were to test the organization of the pathway by implementing it and treating 50 patients in their homes. This phase aimed to adjust the organization decided at the desk to real-life practice, making necessary adjustments before implementing the pathway in all municipalities and starting up a RCT study to evaluate the hospital-at-home treatment pathway. Additionally, it sought to test whether the data required for the evaluation phase, particularly the quantitative data, could be collected. Finally, the phase aimed to study the inter-organizational collaboration between hospitals, municipalities, and GPs at the various organizational levels.\u003c/p\u003e\n\u003cp\u003eThe collaborating organizations\u003c/p\u003e\n\u003cp\u003eThis action research study was conducted in Denmark, involving collaboration between an ED, three municipalities, and GPs. Denmark\u0026rsquo;s free, tax-funded healthcare system ensures all citizens have unrestricted access to GPs and hospital care.\u003c/p\u003e\n\u003cp\u003eThe ED at Viborg Regional Hospital is one of five public emergency hospitals in Central Denmark Region that receive trauma and critically ill patients. The region covers 13,142 km\u0026sup2;, with a population of 1,282,000, including approximately 233,000 residents in the Viborg area, which encompasses the municipalities of Skive, Viborg, and Silkeborg. The ED treats patients referred by GPs and those who call 112, the Danish emergency number. On average, the ED handles 180 elderly patients per week. The ED initiated this study after observing that many elderly patients admitted to the ED could have been treated at home if the appropriate organizational structure had been established.\u003c/p\u003e\n\u003cp\u003eIn Denmark, GPs act as gatekeepers. Every Danish citizen is registered with a GP, who provide initial assessments and referring patients to hospitals or outpatient clinics as needed. They are self-employed, contracted with the government, and compensated per visit and for various services, as well as receiving a fixed annual amount for each registered patient. GPs also organize care during weekends and holidays, rotating shifts at regional out-of-hours centers, where they handle all patient calls. The GPs decide whether to offer phone consultation, directs visit to an out-of-hours GP, refers to a hospital or clinic, or arranges home visits. This study covers about 150 GPs across three municipalities.\u003c/p\u003e\n\u003cp\u003eThe municipalities are responsible for home nursing care, with municipal nurses performing planned tasks. Each municipality also has an acute care team composed of nurses specialized in admission avoidance (Fournaise et al. 2023). These teams are called upon by hospitals to continue patient treatment at home after initial hospital care, by GPs to visit and evaluate patients, or by municipal nurses to assist with advanced nursing tasks.\u003c/p\u003e\n\u003cp\u003eIn this project, the ED, three municipalities, and GPs have been actively involved at various organizational levels from the start. Table 1 illustrates how the various collaborators are involved, categorized according to the factors within the integrated implementation model.\u003c/p\u003e\n\u003cp\u003eTable 1:\u0026nbsp;The various collaborators involved in the project\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.1856%;\"\u003e\n \u003cp\u003eOrganizations/collaborators\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5928%;\"\u003e\n \u003cp\u003eED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5928%;\"\u003e\n \u003cp\u003e3 municipalities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6287%;\"\u003e\n \u003cp\u003eGPs*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.1856%;\"\u003e\n \u003cp\u003eLeadership, steering committee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5928%;\"\u003e\n \u003cp\u003eChief physician\u003c/p\u003e\n \u003cp\u003eHead Nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5928%;\"\u003e\n \u003cp\u003eFrom each of the 3 municipalities: Head of Social and Health Services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6287%;\"\u003e\n \u003cp\u003eTwo representatives from the GPs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.1856%;\"\u003e\n \u003cp\u003eLeadership, task force\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThe task force, consisting of 10 health-care professionals with varying types of knowledge and experience, acted as the action research group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5928%;\"\u003e\n \u003cp\u003eED physician\u003c/p\u003e\n \u003cp\u003eThe manager of the\u003c/p\u003e\n \u003cp\u003ehospital visitation\u003c/p\u003e\n \u003cp\u003eThe manager of the secretaries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5928%;\"\u003e\n \u003cp\u003eFrom each of the 3 municipalities: Head of the acute team and head of the municipality nursing care unit\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6287%;\"\u003e\n \u003cp\u003eA GP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 41.1856%;\"\u003e\n \u003cp\u003eFront-level staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5928%;\"\u003e\n \u003cp\u003eED physicians,\u003c/p\u003e\n \u003cp\u003ehospital visitation nurses, secretaries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.5928%;\"\u003e\n \u003cp\u003eAcute team nurses,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003emunicipality nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.6287%;\"\u003e\n \u003cp\u003eGPs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*\u003c/strong\u003eThe GPs are self-employed\u003c/p\u003e\n\u003cp\u003eThe cross-sectoral hospital-at-home treatment pathway implemented\u003c/p\u003e\n\u003cp\u003eThe hospital-at-home treatment pathway implemented in the first taking action phase is as follows. The physician (GP or out-of-hours medical service), who has seen the patient, calls the hospital visitation placed in the ED. The hospital visitation nurse checks the inclusion criteria and offers the referring physician a joint call, where the referring physician and the ED physician together do a medical assessment of the patient to decide whether the patient can be treated at home. Based on this dialogue, the ED physician, who takes over the treatment responsibility after the call, plans the treatment and calls the municipality acute team.\u003c/p\u003e\n\u003cp\u003eAt the first visit of the municipality acute team nurse, the patient gets oral and written information about the project and informed consent is obtained. If the patient is randomized to hospital-at-home treatment, the acute team nurse starts the treatment. The acute team, who is a group of experienced nurses specialized in providing acute care at home, can measure a patient\u0026rsquo;s vital signs, take ECG, bladder scan, and administer intravenous medications at home. If needed, the acute team takes blood samples and transports them to the hospital\u0026rsquo;s laboratory for processing. The acute team is available around the clock and visits patients whenever required under the treatment. The number of visits by the acute team or homecare nurse depends on the patient\u0026rsquo;s condition. During the treatment daily course, the acute team and the ED physician discuss the treatment either over the phone or virtually on an iPad, where the patient is also involved.\u003c/p\u003e\n\u003cp\u003eIf the physician wants to see the patient for a clinical examination or send the patient for an X-ray, he/she informs the acute team that the patient must undergo a short check-up in the ED. Here, the physician examines the patient him/herself and assesses whether the patient can continue to be in-home treated, or whether the patient must be admitted to the hospital due to deterioration of the condition. In case of an emergency at any time during the day, the patient can call the acute team who comes and checks on the patient. The acute team contacts the ED physician if needed to discuss the patient condition. If the patient is randomized to the control group, the patient will be admitted and receive the standard hospital treatment within the ED. Figure 3 illustrates the hospital-at-home treatment pathway.\u003c/p\u003e\n\u003cp\u003eBy treating patients at home, the ED, municipalities, and GPs form a collaborative network. The ED physician and the municipality acute team play key roles, with responsibilities divided into three stages: (1) input, (2) throughput, and (3) output (Asplin et al. 2003). The GP provides initial examinations during input, while the ED physician oversees treatment and coordinates with the acute team across all stages. The acute team manages care execution and delegates tasks to municipal nurses in the throughput stage. This collaboration requires communication and coordination across sectors but allows ED physicians and acute teams to work closely, \u0026ldquo;outsourcing\u0026rdquo; practical tasks from the hospital to the acute team, and bridges gaps between primary and secondary healthcare systems.\u003c/p\u003e\n\u003cp\u003eMethods and implementation process\u003c/p\u003e\n\u003cp\u003eThe new hospital-at-home treatment model was planned through inter-organizational collaboration (Duvald 2021). Managers and the researcher introduced the acute team, ED physicians, secretaries, and hospital visitation staff to their individual tasks. During the planning phase, the task force developed with the researcher\u0026rsquo;s help written task descriptions for all employees. The task descriptions were adapted to each employee group but intertwined due to a sequential task design. At individual meetings with the researcher, they learned about the context, their specific work tasks, the entire task design, and the research material that the staff should use. Some were introduced for new tools such as a communication platform enabling virtual ward rounds between ED physicians and acute teams. During the initial implementation phase, the researcher was available for support. By late September 2020, the collaborators were ready to treat the first hospital-at-home patient.\u003c/p\u003e\n\u003cp\u003eTo follow and move the implementation process forwards and to address emerging issues, the researcher held online participating dialogue meetings every second month in the task force, consisting of ten practitioners and managers across organizations (Grund\u0026eacute;n et al. 2020). These meetings addressed practical challenges while reflecting on the hospital-at-home pathway implementation. Discussions covered broader topics, such as including more patients, and specific issues, like enabling acute teams to hire taxis for transporting blood samples or ensuring municipal nurses completed forms required for cost calculations.\u003c/p\u003e\n\u003cp\u003eAt the dialogue meetings, the task force addressed challenges in offering hospital-at-home treatment.\u003c/p\u003e\n\u003cp\u003eBased on identified challenges, the researcher collected various data during the initial taking action phase (see Table 2), e.g., to identify inclusion barriers, a self-completion questionnaire was developed and distributed in the hospital visitation. Questions covered topics like the initial talk with referring physicians, collaboration with ED physicians, issues within the hospital visitation, and suggestions for improving inclusion. When doing action research, it is important to reflect on the process and collaboration in order to learn from it. Thus, before one dialogue meeting, each task force member filled out a self-completion questionnaire about the process, and the answers were discussed in plenum at the meeting.\u003c/p\u003e\n\u003cp\u003eSteering committee meetings supplemented the task force meetings. Due to COVID-19, the chair of the steering committee, consisting of the ED chief physician and the head of social and health services from one municipality, held brief online status meetings weekly. Joined by the head of social and health services from the municipality, in which the pathway was implemented, the researcher and the project research adviser discussed adjustments. Every six months, the full steering committee met. A recurring issue was the low number of patients treated at home. Based on a task force suggestion, they decided to implement the pathway in another municipality during the initial taking action phase, requiring additional preparation, which affected the work within the task force. The two municipalities differed in several ways, e.g. the geographical distance to the hospital and acute team capabilities. The researcher acted as a link between the steering committee and the task force and facilitated the cycles of action and reflection as the project progressed.\u003c/p\u003e\n\u003cp\u003eThe project group, consisting of researchers, met to discuss data collection, and the researcher arranged some meetings with the practitioners to address document completion for the research evaluation. To get front-level staff perspectives on the new pathway, roles, implementation, and cross-sector collaboration, the researcher conducted individual interviews with acute team nurses and held two meetings with ED physicians (Kvale \u0026amp; Brinkmann 2009).\u003c/p\u003e\n\u003cp\u003eDuring the first taking action phase, various data collection methods were used to meet objectives and information needs (see Table 2). The study draws on multiple data sources, including audiotaped meetings, interviews, questionnaires, meeting minutes, and documents.\u003c/p\u003e\n\u003cp\u003eTable 2: overview of the various data sources and aim of the data collection\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eType of data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eWho\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eAmount of data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eAim/insights\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eAudiotaped dialogue meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eTask force meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e8 meeting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eDiscussing and solving practical issues within the pathway and the implementation process\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eSteering committee meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e4 meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eInsights of the support to the task force and decisions made across the collaborators.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eSemi-structured interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eAcute team nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e7 interviews with 10 nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eInsights of the nurses\u0026rsquo; experiences with the new patient pathway, their role, collaboration with ED physicians, and implementation. Interviews conducted before implementing the pathway in another municipality.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ePatients and their relatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e4 patients and 3 relatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eInsights of how the treatment model works and how the employees collaborate through first-hand experiences of the target group.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eSelf-completion questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eHospital visitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e14 fulfilled the questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eInsights of the benefits and challenges when including patients\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eTask force members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e11 members, all participated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eInsights of the members individually view on the process and collaboration.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eMeeting minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eChair of the steering committee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e48 morning meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eInsights of the process followed and discussed by the chair in a changing COVID-19 period.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eEmergency physicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e2 staff meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eInsights of the physicians\u0026rsquo; experiences with the new patient pathway, their role, and collaboration with the acute team.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003eInternal documents e.g. project description, work task descriptions, status mails, and newsletters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eInsights of the changes during the initial action research phase e.g. the continuously changes in the work task descriptions and the various challenges addressed in the process.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe implementation process of the action research initiative took about two years. Figure 4 describes the timeline of the process and activities.\u003c/p\u003e\n\u003cp\u003eEthics\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethical Committee, Central Denmark Region (no. 1-10-72-67-20), and all procedures followed were in accordance with Declaration of Helsinki. All patients offered hospital-at-home treatment were informed about the study aim and procedures by an acute team nurse prior to informed consent, which was obtained verbally and written. Employees, patients and relatives, surveyed or interviewed, received written information about the study and participated voluntarily, with all participants anonymized.\u003c/p\u003e"},{"header":"Discussion of learning outcomes based on action research","content":"\u003cp\u003eAs action research has a dual aim: to address an issue and to contribute practical knowledge, we reflect on the action research process itself. Drawing on Coghlan and Shani\u0026rsquo;s framework (2014, 2018; Duvald 2021) that comprises four factors in assessing the quality of an action research initiative, we will discuss the learning outcomes of the first taking action phase within this action research project. The four factors comprise context, quality of relationship, quality of the action research process itself, and the outcomes. Furthermore, within these factors, we will reflect on the factors in the integrated implementation model, including the organizational and inter-organizational implementation behavior, the leadership, and front-level staff behavior (Winter and Nielsen 2008).\u003c/p\u003e\n\u003ch2\u003eContext\u003c/h2\u003e\n\u003cp\u003eCoghlan and Shani\u0026rsquo;s framework emphasizes understanding socio-political, cultural, and structural forces as drivers or inhibitors of organizational change. In this case, the drivers for change in the Danish health system, outline in the introduction, led the three collaborators design and implement a hospital-at-home pathway to improve care for elderly acute ill patients while addressing demographic challenges.\u003c/p\u003e\n\u003ch2\u003eQuality of relationships\u003c/h2\u003e\n\u003cp\u003eThe quality of relationships comprises both how the action research is research \u003cem\u003ewith\u003c/em\u003e people, thus the relationship between the researcher and the practitioner, but also the relationship between the various practitioners (Shani and Coghlan 2021).\u003c/p\u003e\n\u003ch3\u003eRelationship between the researcher and practitioners\u003c/h3\u003e\n\u003cp\u003eGiven the involving nature of action research, the researcher worked closely with the practitioners from the different organizations (and organizational levels within the organizations) in a process of addressing the need for hospital-at-home treatment of the elderly and knowledge generation in the local context of treatment of elderly acute ill patients. The aim was to gather the various experiences about the implementation of the hospital-at-home treatment pathway.\u003c/p\u003e\n\u003cp\u003eIn the taking action phase, researchers and practitioners collaboratively tested actions and adapted the hospital-at-home model to practical reality. A learning environment was fostered where experiences, challenges, and successes were openly shared. Continuous evaluation involved the researcher engaging with employees at the hospital and in the municipalities in daily tasks and formal staff meetings to gather insights. As one acute team nurse noted, the researcher\u0026rsquo;s support was invaluable:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eIt has been a great support to have\u0026nbsp;\u003c/em\u003e(the researcher)\u003cem\u003e, meaning you have had the opportunity to call\u003c/em\u003e \u003cem\u003eand ask. (\u0026hellip;) Because we learn along the way. But I think we have been helped quite well by the fact that\u0026nbsp;\u003c/em\u003e(the researcher)\u003cem\u003e\u0026nbsp;was out here so frequently at the beginning as well as called us.\u003c/em\u003e\u0026rdquo; If the employees came up with ideas for process improvement, such as audits to review patient processes (described further later), they were implemented.\u003c/p\u003e\n\u003cp\u003eResearchers and practitioners also co-developed and tested a micro costing tool for the health economic evaluation. Designed to meet research standards and fit nurses\u0026rsquo; daily routines, the tool benefited from shared ownership. Nurses suggested solutions, like notifying the researcher and nursing team manager via email, when a patient was included, to support accurate form completion. If data were missing, the researcher could follow up with the specific team.\u003c/p\u003e\n\u003ch3\u003eThe organizational and inter-organizational relationships and behavior\u003c/h3\u003e\n\u003cp\u003eThe treatment model and implementation process included three different types of organizations with different interests: a hospital, 3 municipalities, and about 150 GPs. To make the various stakeholders collaborate about the new pathway across organizations, a small-scale collaborative community was established in the planning phase as the underlying project organization (Duvald 2021). A collaborative community brings together multiple stakeholders to work collectively to achieve a common outcome, solve a shared challenge, and leverage collective opportunities in an environment of trust, respect, and openness - without the use of hierarchy as the primary mechanism of control and coordination. The collaborative community was established to address and renegotiate challenges across organizations. Steering committee meetings identified and resolved issues in joint dialogue such as municipalities declining hospital-at-home patients due to capacity, ED physicians adapting to treat patients they did not physically assessed, and changes in GP behavior post-COVID-19. The project\u0026rsquo;s inter-organizational collaboration is supported by the \u0026lsquo;cluster collaboration\u0026rsquo;, a biannual forum, where hospital, municipality, and Prehospital directors as well as GP representatives are updated on project progress.\u003c/p\u003e\n\u003ch3\u003eThe leadership\u003c/h3\u003e\n\u003cp\u003eLeaders from the organizations\u0026rsquo; various levels participated in either the steering committee or task force, showing strong commitment to the project - even though several of them have been replaced during the project period. One example is the chair of the steering committee. The meeting frequency has been high with weekly morning meetings. So high, in fact, that after nine months one of the leaders remarked that he had never experienced such frequent meetings in a project.\u003c/p\u003e\n\u003cp\u003eDuring the first taking action phase, the task force\u0026rsquo;s collaboration shifted, when the steering committee decided to test the pathway in one municipality. Through active participation, this municipality took a leading role, while the others became sparring partners in discussions and evaluations. As one member noted in a written reflection four months in, the task force\u0026rsquo;s role was:\u003cem\u003e\u0026nbsp;that everyone in the group contributes with ideas and proposed solutions; that everyone plays the process well\u003c/em\u003e. \u0026nbsp;Thus, they expected everyone to contribute ideas and solutions and remain committed across organizations.\u003c/p\u003e\n\u003cp\u003eThe role of leadership in transformation is often influenced by information asymmetry between leaders and front-level staff (Winter and Nielsen 2008). In this project, information flow between task force and steering committee members within the municipalities varied. However, the researcher acted as a bridge between employees, task force, and steering committee, by conveying employee challenges, task force questions, and management decisions. If needed, the researcher facilitated connections such as inviting the chair to a task force meeting.\u003c/p\u003e\n\u003ch3\u003eThe front-level staff relationships and behavior\u003c/h3\u003e\n\u003cp\u003eWhen implementing the hospital-at-home pathway, the ED physicians and the acute team nurses got new work tasks. The employee\u0026rsquo;s behavior and performance of these tasks influenced the implementation of the treatment model.\u003c/p\u003e\n\u003cp\u003eThe ED physicians wanted to maintain their tasks similar to their usual routine to minimize resistance, which could reduce the number of patients offered hospital-at-home treatment. As one physician noted: \u0026ldquo;\u003cem\u003eCould it be made easier in terms of documentation? If the instructions can be shaved down to a single page with bullet points, so that you don\u0026rsquo;t have to sit and fight with 4 pages, of which page 3 may be missing - it\u0026rsquo;s just a built-in resistance\u003c/em\u003e\u0026rdquo;. Thus, the tasks and task description were adjusted continuously, e.g. initially the physicians were asked to write journal notes, but they requested dictation and transcription by secretaries instead. This adjustment ensured acute team nurses received written tasks promptly, a requirement for cross-sector collaboration. Additionally, ED nurses now handle ordering samples and tests, further easing physicians\u0026rsquo; workload.\u003c/p\u003e\n\u003cp\u003eThe ED physicians, who are treatment responsible, had to trust referral physician\u0026rsquo;s assessments and the acute team nurses rather than directly evaluating patients, which require time to build confidence. To support this and to ensure quality, a physician suggested evaluating patient cases through audits. The ED management supported the idea. Now, two ED physicians independently review each case to identify delay or deficiencies. Findings are shared with ED physicians, municipality acute teams, the task force, and the steering committee to ensure quality and trust in the process.\u003c/p\u003e\n\u003cp\u003eIn the pathway, the municipality acute team handles home treatment. Most of them find it meaningful and challenging compared to routine tasks, though they were surprised by its complexity. To manage the many tasks, they developed various strategies.\u003c/p\u003e\n\u003cp\u003eOne management strategy was working in pairs, where one performed tasks, while the other followed the task description and ensured all steps were completed. This approach also helped them learn and support each other, especially with time-consuming research-related tasks. Another strategy involved dividing tasks into clinical tasks, research tasks, and collaboration with physicians. One nurse explained: \u003cem\u003eI divide it into three blocks. Because I see it as a completely normal assessment\u0026nbsp;\u003c/em\u003e(\u0026hellip;)\u003cem\u003e\u0026nbsp;then there is a block called contact with the physician - it just happens to be an ED physician, and then there is all the project-related stuff: function test, survey, consent, registration, submission of blood samples. All those things - and that is a block in itself\u003c/em\u003e (\u0026hellip;)\u003cem\u003e\u0026nbsp;And when I can just... ticking of the tasks from the to-do list\u0026nbsp;\u003c/em\u003e(the work task description)\u003cem\u003e, then I don\u0026rsquo;t think it\u0026rsquo;s confusing.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eOthers felt overwhelmed, especially when alone on duty, and used prevention strategies like avoiding tasks on busy weekends. One nurse said: \u0026rdquo;\u0026hellip;\u003cem\u003eI do not want to stress about this, and I do not want to drive around with a guilty conscience and a stone in my stomach. Thus, I decided that every time I have a weekend shift that is too hectic, like the last one, then I will simply say, I cannot do it.\u0026nbsp;\u003c/em\u003e(\u0026hellip;) \u003cem\u003eI support this project, but it cannot work in our weekends. I do not want to walk around feeling sick - having stomach pain. That every time the phone rings, you think, as long as it is not a hospital-at-home patient, you simply cannot do that.\u003c/em\u003e\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eThe nurses agreed that treating patients at home was a learning-by-doing process, requiring ongoing problem solving, and access to support from the researcher, when needed. To support the nurses, the hospital at home treatment pathway was often discussed at local staff meetings, in which the researcher also participated. One thing that was resolved after such a meeting was that the researcher found a solution to a parking challenge at the hospital, when the nurses had to come in to deliver blood samples and pick up medicine. The nurses also found the interviews useful in terms of talking about the benefits and challenges of the pathway.\u003c/p\u003e\n\u003cp\u003eThe collaboration between hospital and municipal healthcare professionals in the hospital-at-home patient pathway is new and built on trust. Written work task descriptions and agreements across organizations have supported this, with adjustments if needed. For example, it was clarified that acute team nurses have the authority to recommend hospitalization, if necessary, as they are physically with the patient. This addition, requested by the nurses, boosted the nurses\u0026rsquo; confidence in their tasks and collaboration with the ED physicians.\u003c/p\u003e\n\u003cp\u003eThe healthcare professionals\u0026rsquo; work task descriptions are interdependent in the sequential pathway, which caused challenges during the start-up phase. Frustrations arose when some employees deviated from their tasks, often due to a lack of understanding of others\u0026rsquo; roles. For example, ED physicians needed to know that an acute team nurse\u0026rsquo;s initial patient visit could take hours, affecting patient inclusion timing. Adjustments were also needed, such as requiring the acute team to notify the hospital visitation in advance, if they lacked resources for hospital-at-home treatment, preventing wasted efforts and unnecessary patient delays.\u003c/p\u003e\n\u003cp\u003eClinicians\u0026rsquo; frustrations from miscommunication in interdisciplinary teams have been reported (Chua et al. 2022). In this project, misunderstandings arose between ED physicians and nurses, such as acute team nurses needing immediate help during calls, otherwise they must drive to another patient, who may live half an hour away, or scheduling ward rounds. In these situations, the researcher acted as a translator and broker to bridge these gaps. Efforts included municipality nurses attending staff meetings with ED physicians and hospital visitation nurses, and an ED physician shadowing the acute team to better understand their tasks.\u003c/p\u003e\n\u003ch2\u003eQuality of the action research process itself (learning cycles)\u003c/h2\u003e\n\u003cp\u003eAction research involves multiple cycles of action and inquiry over time. Some of them are short-term cycles, while others are long-term cycles. The first taking action phase was a learning cycle itself, planned by the task force based on workshop ideas from healthcare professionals. The patient pathway was tested, implemented, and evaluated by employees, the task force, and the steering committee, with many small adjustments made. Though a collaborative learning process, this phase focused on testing and optimizing the pathway through rapid cycle experiments, refining it on a small scale before proceeding to a large-scale implementation of the pathway in all municipalities. Ultimately, the first taking action phase included three larger learning cycles, as shown in Figure 5.\u003c/p\u003e\n\u003cp\u003eWithin the process, the steering committee decided to test the pathway within another municipality. As a part of the expansion from one municipality to another, the experiences from implementing the pathway in the first municipality were used e.g. all the adjustments made in the work tasks descriptions. Moreover, firsthand experiences from the acute team were shared with the other acute team. The acute teams from the various municipalities do not use to share knowledge; however, two nurses were invited to take part in the researchers\u0026rsquo; introduction meeting, which provided the opportunity to initiate a new exchange of experiences across acute teams.\u003c/p\u003e\n\u003cp\u003eHowever, this municipality was different from the first in several ways: the size of the acute team, the competences within the acute team, the location of the acute team, the distance to the hospital, etc. Thus, implementing the pathway in the new municipality required planning, testing, and finding solutions to new challenges.\u003c/p\u003e\n\u003cp\u003eMoreover, due to the upcoming evaluation phase within the action research project including an RCT-study, the pathway for and the cross-sectoral collaboration for the patients in the control group had to plan, test, and evaluate as well.\u003c/p\u003e\n\u003cp\u003eAnother aim was to adjust the organization to practice, and as expected, the implementation did not happen all at once, but as ongoing processes with incremental adjustments. It was found that the employees are good at describing things that did not work and thus it was possible to adjust the work task descriptions. Many minor things were adjusted, and the layout of the descriptions were adjusted.\u003c/p\u003e\n\u003ch2\u003eOutcomes\u003c/h2\u003e\n\u003cp\u003eThe outcome of this phase was the implementation of a hospital-at-home treatment pathway. One of the aims of the first taking action phase was to test the organization of the pathway by implementing it in one municipality, and the overall judgement was that the hospital-at-home organization works; elderly patients can be treated in their homes by the acute team under supervision of the ED physician.\u003c/p\u003e\n\u003cp\u003eAnother outcome is the knowledge about challenges and advantages in the implementation process, which has been created in a joint dialogue across organizations within the project.\u003c/p\u003e\n\u003ch2\u003eLessons learned by going through a slow transition state\u003c/h2\u003e\n\u003cp\u003eCoghlan and Shani (2018, p. 80) describe the transition state between the present and future as challenging, as the old has ended but the new is not yet realized. The COVID-19 situation prolonged this \u0026lsquo;liminality phase\u0026rsquo;, where adjustments to the new way of working went slow. Liminality, as defined by Turner (1967), refers to disorientation experienced during a rite of passage, when participants are between their pre-ritual status and the status they will get, when the rite is complete. In this project, the taking action phase was an in-between period, which frustrated the employees; the pathway was implemented, and the employees adapted a new way of working. At the same time, the pathway was being tested to determine its long-term viability.\u003c/p\u003e\n\u003cp\u003eOne inclusion criterion required the referral physician to see the patient before admission to the hospital-at-home pathway. However, during COVID-19, GPs avoided seeing patients with fever and coughs \u0026ndash; key symptoms the pathway was designed to treat \u0026ndash; resulting in the traditional gatekeeper system being set aside. This environmental change impacted implementation, leading to fewer hospital-at-home admissions than expected and extending the planned three-month phase to two years. Task force members highlighted the prolonged timeline as surprising, and the acute team nurses discussed benefits and challenges with the slow patient inclusion. It hindered learning the workflow, as each case felt like starting over. This complicated the cross-sector collaboration too due to confusion about roles and tasks, leading to frequent discussions. However, the slower pace also allowed time to refine processes, such as ensuring two nurses were present at the first patient visit.\u003c/p\u003e\n\u003cp\u003eTesting of certain pathway elements, like online ward rounds and blood test transportation, also faced delays.\u003c/p\u003e\n\u003cp\u003eDue to the slow inclusion of patients, the steering committee decided to implement the pathway in a second municipality earlier than planned, adding more learning cycles due to differences between the municipalities. Despite this, satisfaction with the number of patients included was noted at meetings, given the challenges of implementing during COVID-19.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study contributes to the growing body of knowledge on the implementation of hospital-at-home models, focusing on the complexities and opportunities of cross-sectoral collaboration. By employing an action research approach, the study not only documented the implementation process but also actively engaged healthcare practitioners in co-creating solutions to organizational challenges.\u003c/p\u003e\u003cp\u003eThe findings demonstrate that trust, communication, and iterative adjustments are essential for fostering collaboration between hospitals, municipalities, and GPs. These factors were critical to aligning diverse organizational practices and ensuring the successful delivery of hospital-at-home treatment.\u003c/p\u003e\u003cp\u003eThe study highlights the importance of integrating front-level staff into the implementation process and adapting workflows to reduce resistance and enhance feasibility. Tools such as structured work task descriptions and collaborative reflective meetings proved effective in addressing barriers.\u003c/p\u003e\u003cp\u003eBy embedding action research within the implementation process, this study facilitated real-time adjustments and generated actionable knowledge. This approach ensured that the organizational model was tailored to the unique needs of the participating stakeholders while maintaining scientific rigor.\u003c/p\u003e\u003cp\u003eThe findings underscore the potential of hospital-at-home models to address demographic and healthcare challenges, offering a patient-centered alternative to traditional hospitalization. Future research should build on these insights to explore long-term outcomes and scalability in diverse healthcare contexts.\u003c/p\u003e"},{"header":"Statements and declarations","content":"\u003cp\u003eEthical Approval\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethical Committee, Central Denmark Region (no. 1-10-72-67-20), and all procedures followed were in accordance with Declaration of Helsinki. All patients offered hospital-at-home treatment were informed about the study aim and procedures by an acute team nurse prior to informed consent, which was obtained verbally and written. Employees, patients and relatives, surveyed or interviewed, received written information about the study and participated voluntarily, with all participants anonymized.\u003c/p\u003e\n\u003cp\u003eInformed Consent to Participate\u003c/p\u003e\n\u003cp\u003eAll patients offered hospital-at-home treatment were informed about the study aim and procedures by an acute team nurse prior to informed consent, which was obtained verbally and written. \u0026nbsp; Employees, patients and relatives, surveyed or interviewed, received written information about the study and participated voluntarily, with all participants anonymized.\u003c/p\u003e\n\u003cp\u003eFunding statement\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Novo Nordisk Foundation [grant number NNF21OC0070180] and the Quality and Training Committee, Central Denmark Region [grant number 1-30-72-29-19].\u003c/p\u003e\n\u003cp\u003eTrial registration number\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable. This paper investigates the implementation of a cross-sectoral admission avoidance hospital-at-home model. In other papers, we investigate the clinical outcomes, thus we have a clinical trial number, however it is not relevant to this paper about implementation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAsplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA Jr (2003) A conceptual model of emergency department crowding. Annals of Emergency Medicine 42(2):173-180\u003c/li\u003e\n \u003cli\u003eBardach E (1977) The implementation game. Cambridge, MA: MIT Press.\u003c/li\u003e\n \u003cli\u003eBradbury H, Lifvergren S (2016) Action research healthcare: focus on patients, improve quality, drive down costs. Healthcare management forum 29(6):269-274\u003c/li\u003e\n \u003cli\u003eBrody AA, Arbaje AI, DeCherrie LV, Federman AD, Leff B, Siu AL (2019) Starting up a hospital at home program: facilitators and barriers to implementation. Journal of the American Geriatrics Society 67(3):588-595\u003c/li\u003e\n \u003cli\u003eB\u0026oslash;llingtoft A, Donaldson L, Huber GP, H\u0026aring;konsson DD, Snow C (Eds.) (2012) Collaborative communities of firms: Purpose, process, and design. New York, NY: Springer\u003c/li\u003e\n \u003cli\u003eCaplan GA, Sulaiman NS, Mangin DA, Aimonino RN, Wilson AD, Barclay L (2012) A meta‐analysis of \u0026ldquo;hospital in the home\u0026rdquo;. Medical Journal of Australia, 197(9):512-519\u003c/li\u003e\n \u003cli\u003eChua CMS, Ko SQ, Lai YF, Lim YW, Shorey S (2022) Perceptions of hospital-at-home among stakeholders: a meta-synthesis. Journal of general internal medicine 37(3):637-50\u003c/li\u003e\n \u003cli\u003eCoghlan D (2019) Doing action research in your own organization (5th ed.). London: SAGE Publications\u003c/li\u003e\n \u003cli\u003eCoghlan D, Shani AB (Rami) (2014) Creating action research quality in organization development: Rigorous, reflective and relevant. Systemic Practice and Action Research 27:523-536\u003c/li\u003e\n \u003cli\u003eCoghlan D, Shani AB (Rami) (2018) Conducting action research for business and management students. Los Angeles, CA: SAGE Publications\u003c/li\u003e\n \u003cli\u003eCovinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D (2003) Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulnerability with age. Journal of the American Geriatrics Society 51(4):451-458\u003c/li\u003e\n \u003cli\u003eCreditor MC (1993) Hazards of hospitalization of the elderly. Annals of Internal Medicine 118(3):219-223\u003c/li\u003e\n \u003cli\u003eDuvald I (2021) Using Action research and organization design to plan in-home hospital treatment. In: (Rami) Shani AB, Noumair DA (ed) Research in Organizational Change and Development 29. Emerald Publishing Limited, Leeds, pp 111-142\u003c/li\u003e\n \u003cli\u003eElmore RF (1982) Backward Mapping: Implementation Research and Policy Decisions: In: Williams W et al. Studying Implementation. Chatman: Chatman House Publishes, Inc.\u003c/li\u003e\n \u003cli\u003eFournaise A, Andersen-Ranberg K, Lauridsen JT, Espersen K, Gudex C, Bech M (2023) Conceptual framework for acute community health care services - Illustrated by assessing the development of services in Denmark. Social Science \u0026amp; Medicine (324) 115857\u003c/li\u003e\n \u003cli\u003eGray B (1985) Conditions facilitating interorganizational collaboration. Human Relations 38(10):911-936\u003c/li\u003e\n \u003cli\u003eGreenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O (2004) Diffusion of innovations in service organizations: systematic review and recommendations. The milbank quarterly 82(4):581-629\u003c/li\u003e\n \u003cli\u003eGrund\u0026eacute;n K, Svensson A, Forsman B, Karlsson C (2020) Dialogue meetings as an arena for collaboration and reflection among researchers and practitioners in a pre-study of a welfare technology testbed. International Journal of Engineering Management and Economics 14(8):629-634\u003c/li\u003e\n \u003cli\u003eInouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR (1999) A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine 340(9):669-676\u003c/li\u003e\n \u003cli\u003eKvale S, Brinkmann S (2009) Interviews: learning the craft of qualitative research interviewing, 2nd edn. Sage, Los Angeles\u003c/li\u003e\n \u003cli\u003eLeff B (2009) Defining and disseminating the hospital-at-home model. Canadian Medical Association Journal 180(2):156-157\u003c/li\u003e\n \u003cli\u003eLeff B, DeCherrie LV, Montalto M, Levine DM (2022) A research agenda for hospital at home. Journal of the American Geriatrics Society 70(4):1060-1069\u003c/li\u003e\n \u003cli\u003eLeong MQ, Lim CW, Lai YF (2021) Comparison of Hospital-at-Home models: a systematic review of reviews. BMJ Open 11:e043285\u003c/li\u003e\n \u003cli\u003eLipsky M (1980). Street-level Bureaucrazy. New York: Russel Sage Foundation\u003c/li\u003e\n \u003cli\u003eMazManian DA, Sabatier PA (1981) Effective Policy Implementation. Lexington: Lexington Books\u003c/li\u003e\n \u003cli\u003eNielsen CP (2021) Implementation. In: J\u0026oslash;rgensen P, Kj\u0026oslash;lby M, Jensen JW (ed) Research, Quality and Clinical Practice. Copenhagen: Munksgaard (in Danish)\u003c/li\u003e\n \u003cli\u003eNielsen CP, Fredens M, Ledderer L (2022) Implementation of Complex interventions. In: Petersen KS, Maindal HT, Ledderer L, Overgaard C (ed) Complex Interventions - Development, Test, Evaluation and Implementation. Aalborg: Aalborg universitetsforlag (in Danish)\u003c/li\u003e\n \u003cli\u003eNilsen P, St\u0026aring;hl C, Roback K, Cairney P (2013) Never the twain shall meet? - a comparison of implementation science and policy implementation research. Implementation science 8:1-12\u003c/li\u003e\n \u003cli\u003eOksuzyan A, H\u0026ouml;hn A, Pedersen JK, Rau R, Lindahl-Jacobsen R, Christensen K (2020) Preparing for the future: The changing demographic composition of hospital patients in Denmark between 2013 and 2050. PLoS One 15(9) e0238912\u003c/li\u003e\n \u003cli\u003ePressman JL, Wildawsky A (1973) Implementation. Berkeley: University of California Press\u003c/li\u003e\n \u003cli\u003eRothman RD, Delaney CP, Heaton BM, Hohman JA (2024) Early experience and lessons following the implementation of a Hospital‐at‐Home program. Journal of Hospital Medicine\u003c/li\u003e\n \u003cli\u003eShani AB (Rami), Coghlan D (2021) Collaborative Inquiry for Organization Development and Change. Edward Elgar\u003c/li\u003e\n \u003cli\u003eShani AB, Eberhardt BJ (1987) Parallel organization in a health care institution: An exploratory action research study. Group \u0026amp; Organization Studies 12(2):147-173\u003c/li\u003e\n \u003cli\u003eShepperd S, Iliffe S, Doll HA, Clarke MJ, Kalra L, Wilson AD, Gon\u0026ccedil;alves-Bradley DC (2016) Admission avoidance hospital at home (review). Cochrane Database of Systematic Reviews 9(9)\u003c/li\u003e\n \u003cli\u003eStrausbaugh LS (2001) Emerging health care-associated infections in the geriatric population. Emerging Infectious Diseases 7(2):268-271\u003c/li\u003e\n \u003cli\u003eThe national association of municipalities (2013) Effective municipal prevention - Focusing on prevention of admissions and readmissions. (In Danish)\u003c/li\u003e\n \u003cli\u003eTurner V (1967) Betwixt and Between: The Liminal Period in Rites de Passage. In The Forest of Symbols. Ithaca, NY: Cornell University Press\u003c/li\u003e\n \u003cli\u003eVale JS, Franco AI, Oliveira CV, Ara\u0026acute;ujo I, Sousa D (2019) Hospital at home: An overview of literature. Home Health Care Management \u0026amp; Practice:1-6\u003c/li\u003e\n \u003cli\u003eWallis JA, Shepperd S, Makela P, Han JX, Tripp EM, Gearon E et al (2024) Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis. Cochrane Database of Systematic Reviews (3)\u003c/li\u003e\n \u003cli\u003eWinter SC (2006) Implementation. In: Peters BG, Pierre J (ed) Handbook of Public Policy. Sage Publication Ltd.\u003c/li\u003e\n \u003cli\u003eWinter SC, Nielsen VL (2008) Implementation of politics. Hans Reitzels Forlag\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"systemic-practice-and-action-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"spaa","sideBox":"Learn more about [Systemic Practice and Action Research](http://link.springer.com/journal/11213)","snPcode":"11213","submissionUrl":"https://submission.nature.com/new-submission/11213/3","title":"Systemic Practice and Action Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7758401/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7758401/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAs healthcare systems around the world face the demographic challenge of aging populations, innovative care models such as hospital-at-home are emerging as promising alternatives to traditional hospitalization. This paper investigates the implementation of a cross-sectoral admission avoidance hospital-at-home model in Denmark, developed collaboratively by a hospital emergency department, three municipalities, and general practitioners. The model aims to provide acute medical care to elderly patients in their own homes, minimizing hospital stays, and reducing risks associated with hospitalization.\u003c/p\u003e\u003cp\u003eEmploying an action research approach, this study captures the dynamic process of implementing the hospital-at-home model. The methodology emphasizes iterative learning cycles, collaborative problem solving, and stakeholder engagement. The implementation process is analyzed using policy implementation theory, with a focus on an interplay between inter-organizational behavior, leadership, and front-level staff roles.\u003c/p\u003e\u003cp\u003eThe findings highlight the importance of trust, communication, and flexibility in fostering effective cross-sectoral collaboration. Practical tools, such as structured task descriptions and regular dialogue and reflection meetings, proved instrumental in overcoming barriers and aligning diverse stakeholder practices. Challenges, including logistical complexities and resistance to role changes, were addressed through real-time adjustments facilitated by the action research approach.\u003c/p\u003e\u003cp\u003eThis study provides actionable insights into the implementation of hospital-at-home models, emphasizing the value of cross-sectoral collaboration and iterative learning. The findings underscore the potential of such models to improve care quality for elderly patients while alleviating pressures on healthcare systems. Future research should focus on evaluating long-term outcomes and exploring scalability in diverse settings.\u003c/p\u003e","manuscriptTitle":"Implementing cross-sector hospital-at-home treatment: challenges, opportunities and action research insights","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 15:53:25","doi":"10.21203/rs.3.rs-7758401/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-22T09:08:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-24T22:00:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-12T21:06:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15944247584624411063379326505772371636","date":"2025-10-08T20:57:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204446203218787928897833088335816699685","date":"2025-10-08T13:38:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"223339599475608835212255011378003741824","date":"2025-10-06T16:41:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-06T09:03:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-06T08:40:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-03T02:04:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"Systemic Practice and Action Research","date":"2025-10-01T09:59:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"systemic-practice-and-action-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"spaa","sideBox":"Learn more about [Systemic Practice and Action Research](http://link.springer.com/journal/11213)","snPcode":"11213","submissionUrl":"https://submission.nature.com/new-submission/11213/3","title":"Systemic Practice and Action Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2389ef07-b094-4ec5-9f05-293313454adc","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-20T07:26:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 15:53:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7758401","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7758401","identity":"rs-7758401","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}