Background:

Contemporary healthcare systems are based on a reductionist, biomedical paradigm maladapted to meet the needs of an aging population with multimorbidity. Integrated care and interprofessional collaboration are suggested to connect the different parts of healthcare. However, how this can be realised is less understood.

The aim of the study was to develop a deeper understanding of how interprofessional collaboration across care providers in transitional care is conducted to achieve integrated care for older people with complex care needs.

Method:

Using constructivist grounded theory, observations and interviews were conducted with healthcare and social care professionals (n=86) from a multidisciplinary and cross-stakeholder perspective in a region in Sweden.

Results:

Interprofessional collaboration in transitional care emerges as a continuum of "Moving from fragmentation to coupling and integration through collaborative efforts". On the lowest level of integration, professionals are working in organisational “silos” that are difficult to cross, as each specialist's expert knowledge is necessary for the vulnerable patient´s wellbeing. Patients´ perception of seamless care is facilitated by the mutual sharing of patient data across organizations through integrated information systems. The highest level of integration is consolidated as the interprofessional team collaborates on a pronounced common ground with a shared mental map of the goals of care, constructing unity for the older person and their family.

Conclusion:

To achieve seamless transitional care for older people with complex care needs, clear boundaries and liability areas are necessary, and actors in interprofessional teams are required to assume responsibility across conceivable gaps across organizations.