Table 1 Individual plan - "The Norwegian model" for cooperation in Primary health care

   1. According to the Patients' Rights Acts municipal health services have the responsibility to set up individual plans (IPs) for "patient who requires long-term, coordinated health service", http://www.ub.uio.no/ujur/ulovdata/lov-19990702-063-eng.pdf)

   2. Municipalities have a coordinating unit responsible for handling initiatives from patients or health-professionals when an IP is wanted and starts the work with the IP for each patient.

   3. A coordinator is appointed in agreement with the patient, normally a person already involved in the treatment or care. GPs are very seldom the coordinator, but are usually included in the process as a medical advisor.

   4. A multidisciplinary team is established, uniquely composed for each IP, based on patient's needs and the services involved.

   5. The coordinator summons the team one to four times a year to plan treatment, rehabilitation and care, and to clarify responsibilities and revise the IP when necessary.

6. In addition to the patient, and/or close relatives, the participants in the multidisciplinary teams are found among professions obligatory in every Norwegian municipality:

Public health nurses

Home service nurses

Mental health workers

Physiotherapists

Occupational therapists

General practitioners

Social workers/children welfare workers

Teachers or special teachers

   7. In addition representatives from the specialist health care representatives from the National Insurance Office often participate