Background: Patients who repeatedly seek care directly at hospital based somatic emergency

departments take up a large proportion of health care resources, at the same time they appear to experience low satisfaction with the care they receive. The purposes of this pilot study were to describe: I) the development of a team model for taking care of frequent visitors to a somatic hospital based ED; II) Eventual changes, over six months, in costs and patients’ health care utilization related to pilot testing the model and III), the team’s experiences of implementing the model.

Methods: A mixed method convergent parallel design was used.

Results: The development of the model began as a top-down process and later on into a bottom-up approach once the inter-professional team became involved. The new model functioned as a support for all 12 patients included in the study and collectively their visits decreased by a total of 73 visits (55%).

Conclusion: The inference quality description is that a management induced project may be accepted and actively applied when those involved experience freedom to structure the project. Increased communication between different professionals within the hospital and between different caregivers such as ED, primary health care and community social- and health-care, increases the possibility for the patients to be cared for in a sustainable and non-fragmented way.