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.

Introduction: Top-level managers in municipal social care administration play a central role in ensuring high-quality care through coordination within and between organisations. However, there is limited understanding of the specific tasks and responsibilities they undertake in this regard. Therefore, this study aimed to explore municipal top-level managers’ perspectives on fostering safe and integrated care for older adults with complex care needs living at home.

Methods: Thirteen top-level managers in municipal social care administration were interviewed. Interview data were analysed thematically.

Results: One theme ‘Leading through trust and empowerment, and encouraging collaborations within and between organisations to foster safe and integrated care’ and five subthemes were identified: ‘Creating conditions for seamless care by minimising cross-organisational barriers’, ‘Using the mandated role when navigating the bigger picture’, ‘Empowering middle managers and nursing staff’, ‘Fostering trust in working towards a common goal’ and ‘Leveraging successful partnerships across organisations’.

Conclusion: Top-level managers see themselves as parts of a larger system that requires them to collaborate with others. Empowering middle managers and nursing staff to thrive in their roles, through leadership based on trust, promotes a unified effort toward the common goal of safe and integrated care for older adults with complex care needs.

Introduction

Integrated care has the potential to mitigate patient safety risks by enhancing collaboration andmaintaining a patient-centred approach. However, best practices for successful implementation are lacking. This study aims to identify and describe key components of best practices for integrating health and social care to increaseunderstanding of successful implementation.

Methods

A Collaborative Reflexive Deliberative Approach was used. The data comprised twenty-one publishedarticles and five unpublished manuscripts from 2015 to 2023, along with the experiences of ten clinicians andresearchers in integrated care, and the research team itself.

Results

Components identified as best practices for integrated care, each describing different aspects shaped by andfor the patient, were: holistic co-creation in an ethical stance, trust through physical and relational proximity, flexiblecaring, learning and adaptable organizations and flexible information and communication.

Discussion/conclusion

The study emphasizes the importance of building trust through proximity and adaptableorganizational learning, and the need for a holistic perspective, acknowledging both the limitations and potentialsof health and social care integration. Embracing innovative thinking and recognizing that not everyone needs allservices at all times can foster flexible, person-centred integrated care. Addressing these complexities is essential forsuccessful integration efforts.

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: Although coordination of care and integrated care models aim to enhance patient satisfaction and perceived care quality, evidence regarding their practical implementation remains scarce. Understanding the nuances of collaboration across care providers to achieve effective coordination of care is imperative for seamless care integration. The aim of this study was to construct a grounded theory of how inter-organizational collaboration is performed to support coordination of care for patients with complex care needs.

Methods: A qualitative design with a constructivist grounded theory approach was applied. In total, 86 participants with diverse backgrounds were recruited across multiple care settings, including hospitals, ambulance services, primary care centers, municipal home healthcare and home care services. The grounded theory was developed iteratively, based on a combination of observations and interviews, and using constant comparative analysis.

Results: Coordination of care, a complex process that occurs across interconnected healthcare organizations, is manifested as “Negotiating care in organizational borderlands.” Care coordination evolves through a spectrum of inter-organizational collaboration, ranging from “Dividing care by disease-specific expertise” to “Establishing paths for collaboration” and ultimately “Co-constructing a comprehensive whole.” These categories highlight the challenges of coordinating care across both professional and organizational boundaries. In the multifaceted healthcare landscape, effective care coordination occurs when healthcare professionals actively bridge the divides, leveraging their collective expertise. Importantly, organizational boundaries may serve a purpose and should not be dissolved to facilitate effective care coordination.

Conclusions: The key to effective care coordination lies in robust inter-organizational collaboration. Even when patients receive integrated care, healthcare professionals may have fragmented roles. This research emphasizes the importance of clearly defined lines of accountability, reinforcing mutual responsibility and facilitating bridging of professional and organizational boundaries. Healthcare professionals and policymakers can use these insights to effectively utilize inter-organizational collaboration in supporting care coordination for patients with complex care needs.

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 number of older adults with complex healthcare needs is growing alongside limited resources available in health services. To meet this challenge, it is urgent that healthcare staff are motivated and able to continuously translate new knowledge and working methods into daily practice. To facilitate such implementation, supportive measures responding to the healthcare personnel’s needs seem essential. The present study aims to translate, contextualize and test a Swedish version of the Implementation Process Assessment Tool (IPAT) for measuring the facilitation needs among staff implementing a new working process in municipal elderly care.

Methods

A mixed-method design was used. First, the existing instrument was translated into Swedish. Thereafter, twelve staff members with different professions working in healthcare and at the municipal elderly care were interviewed using Think-aloud interviews to contextualize and test the face validity of the translated instrument. Lastly, the adjusted instrument (Swe-IPAT) was psychometrically evaluated through a cross-sectional survey among 305 staff members working in municipal elderly care.

Results

The psychometric evaluation of the Swe-IPAT revealed satisfying properties. Three factors, largely in line with the original IPAT, are suggested. Internal consistency assessed using Cronbach’s alpha was 0.93 for the factor individual phases for behavioral change and perception of the intervention, 0.84 for the factor individual activities, and 0.95 for the factor collective readiness and support.

Conclusions

The 27-item Swe-IPAT, translated into Swedish and contextualized, demonstrated satisfactory psychometric properties when tested in an elderly care context. The instrument is suggested to be useful in providing feedback to managers in tailoring support and assessing implementation efforts among healthcare staff in elderly care. However, more research is needed to evaluate its properties throughout the entire implementation process and to test the usability of Swe-IPAT in other settings.

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.