Planning out: coordination of health and social care services for older people with dementia when discharged from inpatient care

Research problem and specific questionsWhen a person with dementia is discharged from hospital care, Swedish law requires that different responsible agencies have a joint care plan meeting to organize the persons health and care services.

The person also has the right to participate in decisions concerning their future health and care services.By having a focus on the discharge process and care plan meetings, this proposed research project will explore a) how collaboration and coordination between various care providing agencies (regions and municipalities) can be developed further and b) how older people with dementia can be encouraged to participate in the process of coordinating future health and social care services.

Based on these explorations, a grounded-theory based model for how collaboration and coordination of the discharge process will be developed.Data and methodData is generated through qualitative methods: WP1) audio recordings from care plan meetings, WP2) interviews with professionals, officials, and politicians responsible for collaboration and coordination of services, WP3) dyadic interviews with people with dementia and significant others.

WP4 will use all collected data.

Discourse analysis (WP1), thematic content analysis (WP2-3), and grounded theory (WP4) will be used.RelevanceHealth and social care for older people in Sweden have been criticized for structural deficiencies such as fragmentation, poor coordination, and unclear transfer of responsibility between authorities’, agencies, and actors.

Knowledge of how services are coordinated when people with dementia are discharged from inpatient care is scarce.

The project enhances knowledge on how collaboration takes place in practice and how it is experienced by various actors.

A thorough understanding of the problem is crucial to improve the process and in the development of a model to facilitate coordination and collaboration between various actors.Plan for project realizationApproval from four municipalities in two regions to participate in the project is facilitated through established contacts.

Meetings with projects advisory board (ongoing process). Data collection and analysis will be carried out continuously during the project. In WP4 all data sets and generated knowledge are used to develop a model for collaboration and coordination.

The model will be discussed with the advisory board and members of the public through different dissemination activities.