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-V) 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) together with an experience-based co-design to develop a model for care transition (phase II), feasibility study of the (phase III), evaluate the effect of a revised model in a cluster randomized controlled trial (phase IV).

The data set leveraged in phase I 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. Phase II has been finalized and an experience-based co-design approach was used to develop a new model for the coordination of care at discharge, called MOSAIC. In phase III, the co-designed new model of coordination of care has been evaluated in regard to feasibility, analyses are ongoing. In phase IV 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 III. The primary outcome in the cluster RCT will be total costs. This project 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.