Elisabeth Rydwik

Research problem and specific questionsCoordination of healthcare activities is of particular importance for older people in need of geriatric care as they often have multiple conditions and health related needs, requiring  care from several providers. The overall aim of this research project is to introduce and evaluate a person-centered care transition model that is currently being developed through co-creation with end-users to improve the coordination of care after discharge from geriatric inpatient care. The project is divided in three phases with the following research questions: (1) is the new care transition model feasible in a local setting? (2) is the care transition model effective when evaluated in a cluster randomized-controlled trial (RCT)? (3) what are the prerequisites for implementation and how do patients, next of kin and staff experience the care transitions process?Data and methodPhase I is a feasibility study where the new model will be evaluated in terms of fidelity, applicability and acceptability using focus groups, individual interviews and questionnaires. We will also evaluate the model’s preliminary effect on total costs after discharge, their distribution between payers, and rate of readmission using register data. In phase II and III a refined model (based on the results from the feasibility study) will be introduced and evaluated with an effect and process evaluation using the same type of methods as in phase I. The primary outcome in the cluster RCT will be total costs.Societal relevance and utilizationThis proposal targets the societal challenge of providing coordinated services between social services and healthcare to an aging population in a fragmented system. If coordination of care between different responsible providers of health and social care is improved, it may have significant positive impact for the older adults, involved staff, and the society. This project takes an overarching approach and evaluates costs across the health and social care system.Plan for project realizationFOU nu (asset manager) has a close collaboration with the geriatric departments in the region, the primary care centres and units within the municipalities as well as with patient representative organizations that we are collaborating with in the ongoing project. This, as well as ongoing collaborations with other R&D-units within the region, gives us an excellent possibility to ensure that the project is realized as described.

Research problem and specific questions The overall aim is to develop models that support older adults´ participation in everyday activities that engage and lead to well-being where welfare technology is used to reduce the need for primary- and homecare.The needs of older adults at risk/ with frailty and significant others participating in interventions using digital technologies and what is needed for successful implementation will be studied together with the older adults, significant others, informal carer and staff.Research questions Can a prevention program using technology supporting engaging activities in everyday life reduce risk or maintain/delay the level of frailty in older adults? (project A)How can a prevention program that use technology support “Good quality, local health care “for frail older adults become a self-evident and integrated way of working as an addition to physical care within primary healthcare? (project A)Can a specialized homecare service (Reablement) using technology support older adults’ participation and engagement in everyday life while living at home? (project B)What are the needs of informal carer who provide support to older adults living with frailty at home? (project A-D)What are the systemic factors for and how can co-creation methods contribute to successful implementation of an intervention using technology directed towards older adults to improve primary care and homecare services? (project A-E)                                                                                                                                                                Data and method The interdisciplinary program is based on tested interventions using digital technology with positive effects in the context of older adult’s home. Five projects with qualitative and quantitative methods are planned. A digital platform will be used to compare data. With analyses from projects A-D, a model describing effects of implementation that can change and implement new interventions and working approaches using will be developed (project E).Relevance and utilisation In Europe, more than 1/3 of older adults &lt

75 years live with frailty that causes functional limitations with an impact on well-being of many older adults thats lead to high costs for tax-funded care.The home is an important arena and with an increase of older adults new working models are needed. The result will generate knowledge about how to use digital solutions for preventive efforts, more efficient primary- and homecare that enable participation in everyday life of older adults and support for relatives and staff.Plan for project realisation A close collaboration between staff in Region Stockholm/Uppsala, City of Stockholm, Huddinge municipality and researchers at Karolinska Institutet, Royal Institute of Technology and Uppsala University that will work closely to a reference group of older adults, significant others, and stakeholders.