Coordination of care after discharge in a complex healthcare landscape – today’s situation and a possible way forward

Older adults make up approximately 20% of the Swedish population.

The ongoing demographic development, with an ageing population and a continuously larger proportion of older adults, leads to continuously increasing demand for appropriate and efficient geriatric care.

One particularly critical moment in the continuum of care for older adults is the transition between different responsible authorities, between regional and municipal care.The project consists of four phases and the aims are (I) to map and assess the situation in terms of health, care activities and resource use after discharge, (II) analyse associations with care-transition outcomes, (III) based on phase I-II, generate viable ideas for addressing and improving the situation, and (IV) implement new and improved ways of working as well as perform a post-implementation evaluation of effects (IV).

The design of the study is closed cohorts based on registry data (phases I-II) together with an experience-based co-design (phase III), implementation and evaluation (phase IV).The data set leveraged in phases I-II consists of patient records from geriatric care, health care utilization data for six months after discharge extracted from the Stockholm Regional Healthcare Data Warehouse, socioeconomic data from Statistics Sweden, and data from the National Board of Health and Welfare on social services and death cause.

In phase III, an experience-based co-design approach will be leveraged to develop a new model for the coordination of care, where the synthesised knowledge from phases I-II will be used as a base. In phase IV, the co-designed new model of coordination of care will be implemented.

To be able to draw adequate conclusion from the outcome analyses, data on the process of implementation will be collected, and frequency of readmission will be the primary outcome measure to evaluate the effect of new ways of working. Costs of readmission will be computed before and after implementation.