Coordination of care after discharge in a complex healthcare landscape

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.

Principal investigator

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Elisabeth Rydwik

Senior Lecturer/Physcial Therapist

Project members

Anne-Marie Boström, docent

Lennart Carlsson, PhD

Martin Dreilich, PhD, Familjeläkarna

Stefan Fors, docent

Ameli Lindh Mazya, PhD student

Rikard Lindqvist, PhD, Stockholm County Council, SLSO

Gunnar Nilsson, professor

Rosalind Pfaff, PhD student

Carl Willers, postdoc

Publications from the Risk factors for readmission project

Social Services Post-discharge and Their Association With Readmission in a 2016 Swedish Geriatric Cohort.
Pfaff R, Willers C, Flink M, Lindqvist R, Rydwik E
J Am Med Dir Assoc 2024 Feb;25(2):215-222.e3

Downton Fall Risk Index during hospitalisation is associated with fall-related injuries after discharge: a longitudinal observational study.
Mojtaba M, Alinaghizadeh H, Rydwik E
J Physiother 2018 07;64(3):172-177

Health status and health care utilization after discharge from geriatric in-hospital stay - description of a register-based study.
Rydwik E, Lindqvist R, Willers C, Carlsson L, Nilsson GH, Lager A, Dreilich M, Lindh Mazya A, Karlsson T, Alinaghizadeh H, Boström AM
BMC Health Serv Res 2021 Jul;21(1):760

Readmission within three months after inpatient geriatric care-Incidence, diagnosis and associated factors in a Swedish cohort.
Willers C, Boström AM, Carlsson L, Lager A, Lindqvist R, Rydwik E
PLoS One 2021 ;16(3):e0248972

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