Janne Agerholm

Research problem and specific questions Sweden’s population is ageing, and the prevalence of multimorbidity and functional limitations is increasing. This puts strong demands on effective coordination between health and social care. The Coordinated Individual Plan (CIP) is intended as a tool to ensure better coordination between health and social care providers. However, previous evaluations show uneven implementation and unclear effects of CIP. This project aims to identify factors that facilitate or hinder CIP implementation, and analyse its impact on healthcare utilisation and costs. The study will also examine differences in access to CIPs based on sociodemographic factors, with the goal of contributing to more equitable care. Finally, concrete strategies will be developed to translate the research findings into actionable recommendations for care practice. Data and methods The project applies a multi-method design. Qualitative interviews with older adults and their relatives will explore experiences of receiving a CIP after discharge. Focus groups with both regional and municipal professionals will identify challenges and best practices for achieving good coordination. Register-based analyses will investigate effects on healthcare utilisation and costs, as well as differences between population groups. In addition, co-creation workshops with staff, decision-makers, and user organisations will be used to develop practical strategies for strengthening the use of CIPs. Societal relevance and utilisation By clarifying barriers and facilitators for the implementation of CIP and analysing its outcomes, the project provides knowledge that can be used to develop more person-centred, equitable, and efficient care. Co-creation workshops with stakeholders will ensure that results are translated into guidelines, training, and new working methods, making them directly applicable in the ongoing transformation towards God och nära vård (care closer to home). Plan for project realisation The project will run for four years and be conducted by an interdisciplinary team with expertise in health services research, social gerontology, epidemiology, and health economics. An advisory board of practitioners and user representatives will be closely involved. Results will be disseminated through scientific and popular science publications, policy briefs, and seminars, with the overall aim of strengthening coordination and improving care for older adults with complex needs.

Research problems: The Swedish healthcare system has become very specialised and is often experienced as fragmented and lacking coordination between caregivers. Advanced age is associated with multi-morbidity, which usually requires care from several different caregivers. This makes older people vulnerable to fragmentated care and lack of care coordination. Health literacy (HL) is an essential component of an individual’s ability to gain access to, understand and use information to improve and maintain good health and is an important prerequisite for managing health and care needs. Therefore, knowledge on older people’s HL is vital to efficiently and equitably meet the care needs of the rapidly aging population.Specific questions: The project aim is to gain knowledge on HL in the older population. In this project we will assess to what degree the older population in Sweden is health literate, identify groups that might face challenges due to inadequate HL and explore what older people experience as prerequisites for understanding health information and managing their health and care needs as well as communicate with caregivers.Data and Methods: This project combines both qualitative and quantitative data. The Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD), linked with register data on healthcare utilisation will allow for measuring the level of health literacy in a nationally representative sample of the Swedish population aged 77 years and over. Semi-structured interviews with older people will be performed to deepen the understanding of contextual barriers and facilitators, and individual internal and external resources to make informed decisions about their health and care needs. Plan for project realisation: The collection of SWEOLD data is in progress and preliminary analyses on a sub-sample have been performed. Information about HL, life situation, health, care utilisation, physical and cognitive ability and social support from relatives are being collected. The project group has extensive knowledge about older adults, health literacy, the health and social care system as well as relevant research methodology, both qualitative and quantitative.Relevance: Knowledge on HL among the older population can be used to tailor communication and directing support to vulnerable groups in order to achieve an efficient and equitable health and social care system, as well as supporting older people in health crisis, like the COVID-19 pandemic.