Open Access

Britta Tetzlaff, Ana L. Mazur, Uta Sekanina, Tilman Huckle, Richard Dano, Carolin Höckelmann, Marilena Diel, Lea Bremer, Anja Kühn, Anna-Marie Romanski, Sarah Kuba, Thomas Ruppel, Katrin Balzer, Sascha Köpke, Indre Maurer, Clarissa E. Weber, Martin Scherer, Eva Hummers, Christiane A. Müller

• Background: People receiving home care (PRHC) usually have complex healthcare needs that require the involvement of informal caregivers and health professionals. Interprofessional collaboration is an important element of person-centred home care, which is often insufficiently implemented. This study aims to explore current practices of collaboration in the home care setting and develop an interprofessional person-centered care concept. Methods: The care concept was developed iteratively by incorporating theory and evidence and involving interest holders. The evidence was synthesized from a literature review, semistructured interviews with PRHC (n = 20) and relatives (n = 21), three mono-professional focus groups each with nurses (n = 17), general practitioners (n = 14) and therapists (n = 21). The findings were discussed in four mixed focus groups (n = 37). Qualitative data were analysed using content analysis. In addition, a survey involving PRHC and relatives (n = 37), nurses (n = 70), general practitioners (n = 33) and therapists (n = 81), and eight best-practice cases were explored based on nine home visit observations, 29 interviews and shadowings using principles of grounded theory. The quantitative data were analysed descriptively. Finally, the care concept was outlined in an expert workshop (n = 25) and finalised in a co-creation workshop (n = 12). Results: The developed interprofessional, person-centered care concept for PRHC includes five components: the designation care coordinators, an initial joint home visit, a secure digital communication system, a dedicated phone number for quick contact, and additional joint meetings as needed. The approach highlights individualized, goal-oriented care plans, sustained and effective interprofessional collaboration, and active engagement of PRHC and their relatives in refining and delivering care in accordance with their own goals and needs. An accompanying logic model supports systematic guidance for planning, implementation, and evaluation, enhancing the likelihood of success and ensuring a transparent, well-structured process. Conclusions: Interprofessional, person-centred approaches to home care in Germany should focus on improving communication, shared responsibility and joint care planning between PRHC, relatives and healthcare professionals. The aim of the developed care concept is to improve quality of life and reduce hospital admissions of PRHC. This concept will first be evaluated and refined in a cluster randomized controlled trial. Trial registration: This study is registered on ClinicalTrials.gov as NCT05149937 on 03/11/2021. Study part A completed.