A Collaboration Model Between Patient Organizations and Municipal Health Service

Background: Rheumatic and musculoskeletal diseases (RMDs) are the leading cause of disability and work absence in Norway. Although strong evidence supports physical activity, self-management and peer support, rehabilitation pathways remain fragmented. Capacity in specialist rehabilitation is declining, several specialized institutions have closed due to reduced funding, waiting times are long, and many municipalities lack coordinated follow-up for people with RMDs. There is limited awareness of available rehabilitation and follow-up options, including municipal Healthy Life Centres and initiatives in the voluntary sector. Insufficient awareness may contribute to delayed intervention, functional decline and reduced participation in working life, highlighting the need for stronger cross-sector collaboration.
Objectives: To develop a scalable collaboration model that links voluntary peer-support resources in patient organizations with municipal health-promotion services, improving access to structured self-management support with trained peer supporters for people with RMDs.
Methods: NRF facilitates peer-led self-management courses, Chronically Active, delivered by trained volunteer peer supporters certified as “Healthy Life Agents”. Through co-creation workshops and dialogue with volunteers and municipal partners, a practical collaboration model was developed and tested. The model defines roles, communication routines, shared responsibilities and procedures for implementing peer-supported courses within municipal Healthy Life Centres. A visual model and accompanying brochure support planning, delivery and evaluation, enabling predictable and sustainable collaboration between municipalities and voluntary organizations. The model is called Frisklivsmodellen (“the Active Living model”).
Results: The Active Living initiative has resulted in a national collaboration model that clarifies how municipalities and voluntary organizations can jointly deliver self-management support to bridge gaps in rehabilitation services. The model expands access to peer support, improves awareness of available services, reduces fragmentation, and supports earlier, more continuous follow-up for people with RMDs - particularly those who do not qualify for specialist rehabilitation.
Conclusions: Integrating voluntary peer-support programs, such as Chronically Active into municipal health-promotion services, offers a feasible, scalable, and sustainable approach to addressing rehabilitation gaps for people with RMDs. This collaboration model provides a clear framework for implementing low-threshold, structured courses that strengthen self-management, enhance participation in working life, and a concrete advocacy tool for improving equitable rehabilitation pathways across Norway.