2324252627282926 of 34
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Interlacing the threads of seamless care: Interprofessional collaboration in care transitions for older people with complex care needs
Linnéuniversitetet, Fakulteten för Hälso- och livsvetenskap (FHL), Institutionen för hälso- och vårdvetenskap (HV). Region Kalmar County (SWE).
Linnéuniversitetet (SWE).
Linnéuniversitetet (SWE).ORCID iD: 0000-0001-7552-2717
Linnéuniversitetet (SWE).ORCID iD: 0000-0002-3381-5893
Show others and affiliations
2022 (English)Conference paper, Oral presentation with published abstract (Refereed)
Abstract [en]

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

Place, publisher, year, edition, pages
Ubiquity Press , 2022. Vol. 22, p. 360-360
Series
Serie International Journal of Integrated Care, E-ISSN 1568-4156
National Category
Other Health Sciences
Identifiers
URN: urn:nbn:se:hv:diva-23453DOI: 10.5334/ijic.ICIC22185OAI: oai:DiVA.org:hv-23453DiVA, id: diva2:1967749
Conference
International Conference on Integrated Care, Odense, Denmark, 23-25 May 2022
Note

CC BY 4.0

Available from: 2025-06-12 Created: 2025-06-12 Last updated: 2025-06-12

Open Access in DiVA

fulltext(289 kB)13 downloads
File information
File name FULLTEXT01.pdfFile size 289 kBChecksum SHA-512
5c8faf6f1f892038e2cf0c5d604d408b7285a49c17010a6ebc316a372f382df8ce9c937be41ba530c55bc3dec44ef5cd7034c0944f5eb76696acd0e402a6d0b7
Type fulltextMimetype application/pdf

Other links

Publisher's full text

Authority records

Svensson, Ann

Search in DiVA

By author/editor
Lindberg, CatharinaHagerman, HeidiSvensson, AnnEkstedt, Mirjam
By organisation
Divison of Informatics
Other Health Sciences

Search outside of DiVA

GoogleGoogle Scholar
Total: 13 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

doi
urn-nbn

Altmetric score

doi
urn-nbn
Total: 36 hits
2324252627282926 of 34
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf