Older adults' involvement and participation in coordinated care transitions from in-patient care to home

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.