Purpose

This study aimed to explore and describe how coordinated care transitions aligned with legislation when older adults are discharged from in-patient care to their homes.

Methods

A mixed-method (QUAL + qual) design was used. The core data component (QUAL) consisted of copies of 15 older adults' healthcare and social care records. The supplementary data component (qual) encompassed individual interviews. All data related to the same older adults, whose coordinated care transitions took place between January to June 2022. The analytical procedure followed a deductive thematic analysis.

Results

Findings showed that individual care plans were often missing or inadequately documented. Documentation of older adults' participation was frequently poor and inconsistent, with many decisions made without their input. However, some documents and interviews indicated that older adults had genuinely participated. The discrepancy between documented procedures and actual experiences reveals significant variability in older adults' inclusion.

Conclusion

This study highlights the frequent exclusion of older adults from coordinated care transition process and deficiencies in documentation. The findings underscore the urgent need for standardized and inclusive documentation practices, as well as improved communication strategies, to ensure more person-centred care transitions, in which older adults are genuinely involved and well-informed about their care transitions.

Background The growing number of older adults with chronic diseases challenges already strained healthcare systems. Fragmented systems make transitions between healthcare settings demanding, posing risks during transitions from in-patient care to home. Despite efforts to make healthcare person-centered during care transitions, previous research indicates that these ambitions are not yet achieved. Therefore, there is a need to examine whether recent initiatives have positively influenced older adults' experiences of transitions from in-patient care to home. This study aimed to describe older adults' experiences of being discharged from in-patient care to home.Methods This study had a qualitative descriptive design. Individual interviews were conducted in January-June 2022 with 17 older Swedish adults with chronic diseases and needing coordinated care transitions from in-patient care to home. Data were analyzed using inductive qualitative content analysis.Results The findings indicate that despite being the supposed main character, the older adult is not always involved in the planning and decision-making of their own care transition, often having poor insight and involvement in, and impact on, these aspects. This leads to an experience of mismatch between actual needs and the expectations of planned support after discharge.Conclusions The study reveals a notable disparity between the assumed central role of older adults in care transitions and their insight and involvement in planning and decision-making.

Background: The growing number of older adults worldwide coupled with chronic disease challenges already strained healthcare systems. Healthcare and social care is obliged to coordinate care and support upon discharge. In addition, individuals have a legal right and willingness to participate in the planning for support. Despite efforts to make healthcare person-centered and improve the interaction between different healthcare providers in clinical practice, previous research indicates that healthcare systems remain fragmented, having poor coordination when delivering care.

Aim: To describe older adults' experiences of being discharged from in-patient care to home.

Methods: This study had a qualitative descriptive design, enabling straight descriptions of older adults' experiences of being discharged from in-patient care to home. Individual semi-structured interviews were conducted with 17 older adults (aged 65 years, or older) living in the south of Sweden, with chronic diseases and in need of coordinated care transitions. Data were analyzed using inductive qualitative content analysis.

Results: The analysis yielded four generic categories and the main category “Being the main character but not always involved in one's own care transition”. This indicates that older adults are not always involved in the planning and decision-making regarding their care transition leading to a mismatch between actual needs and the expectations of planned support after discharge.

Conclusions: The study reveals a notable disparity between the assumed central role of older adults in care transitions and their insight and involvement in planning and decision-making. The findings are significant in the context of person-centered care, which emphasizes the importance of tailoring healthcare services to the individual's unique needs and preferences.

Background: The growing number of older adults with chronic diseases challenges already strained healthcare systems. Transitions between healthcare settings, such as moving from in-patient care to home, carry risks in fragmented healthcare systems. Despite the recognized importance of increased patient involvement in addressing healthcare challenges, significant challenges persist in care transitions from in-patient care to home, particularly for vulnerable older adults with chronic diseases.

Aim: To describe and generate knowledge regarding older adults' involvement and participation in coordinated care transitions between healthcare and social care services, from in-patient care to home.

Method: This thesis is based on two studies. Study I had a qualitative descriptive design. Data were collected using individual interviews (n=17) and analyzed using inductive qualitative content analysis. Study II had a QUAL + qual mixed-method design. Data comprised two simultaneously collected datasets, including healthcare and social care records, coordinated individual plans, and discharge plans (QUAL), and individual interviews (qual) with older adults (n=15) concerning specific care occasions. These were analyzed using thematic analysis.

Results: Older adults recounted experiences of being the main character of their care transition, but not always being involved. This was apparent through varied experiences of having insight into, being involved in, and/or having an impact on their care transition process. The outcome was an experience of mismatch between the expectations of planned support after discharge and the actual needs (Study I). Study II highlighted significant inadequacies in how healthcare professionals documented individual plans, including discharge plans and coordinated individual plans. The records often failed to accurately reflect the extent of older adults' participation in the planning and decision-making process. Similarly, the documentation within both healthcare and social care records inadequately captured the level of involvement of older adults. Despite these shortcomings, care coordination among healthcare professionals was generally effective, although important information was not always communicated to the older adults themselves.

Conclusions: The results indicate that although care transitions for older adults discharged from in-patient care to home are generally well coordinated among healthcare professionals, there are shortcomings in ensuring older adults' involvement and participation in planning and decision-making regarding their care and support.

Introduction: Current healthcare systems are not optimally designed to meet the needs of aging populations. With shorter hospital stays, fewer hospital beds, and fragmentation of the healthcare system, older people with complex care needs are recognised as particularly vulnerable. This development further increases the demands on older people and their family to assume responsibility of own health, and to navigate through the healthcare system, knowing of when and where to seek help. In care transitions, an interprofessional collaboration across care providers is considered as a path to deliver seamless care. Still, it seems hard to achieve.

Aim and Method: The aim of the study is to explore interprofessional collaboration in care transitions from inpatient care to home healthcare for older people with complex care needs.

Care transitions involve a variety of healthcare teams across stakeholder boundaries. Hence, to study this extensive process, an explorative qualitative methodology was chosen, using Constructivist Grounded Theory. The sampling approach was guided by the continuous analysis of the collected data, utilizing a theoretical sampling. Fifty-nine multidisciplinary healthcare and social care professionals (HSCP) from different stakeholders were recruited. Document analysis, participatory observations and semi-structured interviews were conducted and analysed according to Charmaz.

Results: Collaborating for a comprehensive care of older people with complex care needs emerges as interlacing the different threads of care to construct seamless care. Organizational gaps and legislations divide the HSCP as they strive to perform safe care within system boundaries, limited by interdependencies and communication organized in silos. Care is integrated as HSCP assumes accountability by going above and beyond their responsibility, constructing unity for the older person and their family. Seamless care is facilitated when information systems are integrated and by mutual sharing of patient data across organizations. To achieve seamless care for older people with complex care needs, HSCP need to adapt the delivery of care to the older person’s needs and resources instead of performing care as per organizational boundaries and conditions. Further, the autonomy of older people and their families need to be strengthened, including them as partners in the collaboration and coordination of care.

Conclusions: Care efforts for older people with complex care needs are visualized as threads that together create a comprehensive care. To weave the threads together, a collaborative effort is required, strengthening the autonomy of the older person and their family, supported by integrated information systems that coordinate the care seamlessly.

Implications and limitations: This study contributes to the understanding of interprofessional collaboration in care transitions of older people with complex care needs. Key strengths include the rich data and multidisciplinary perspective on providing integrated care. Limitations concern the absence of patient, family and informal caregivers’ involvement which should be included in further studies.