Maria Flink

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 questionsWorldwide, welfare societies strive to overcome fragmentation of services through increased integration. Despite this, evidence and support is lacking to guide local actors in social services and primary care on how to co-create integration with and for end users, such as older people. The aim is to, together with local actors and older people, develop and evaluate a research-based toolbox to integrate services for older people in need of both social services and primary care.What support do local actors need to co-create, test and monitor improvements of integrated services?What content, structure and design are needed in a toolbox to support local actors in co-creating, testing, and monitoring integrated services?What is the feasibility, perceived value, and impact of the toolbox?Data and methodThis participatory action research project comprises of three work packages (WP). In WP 1, we will use a participatory, longitudinal multiple case study design including four cases to explore actors’ need of support. In WP 2, we will use a Delphi-study design and participatory methods to develop the toolbox. In WP 3, we will use an observational case study design to evaluate feasibility, value, and impact. Data will be generated through structured and semi-structured observations, focus group and individual interviews, and surveys. Data will be analyzed with qualitative and quantitative methods.Societal relevance and utilisationA welfare society reform is launched in Sweden to integrate services and meet the needs of an aging population. However, the task of developing, implementing, and evaluating integrated services is a complex challenge that requires collaborative approaches, involving multiple stakeholders and end users. Yet, this task has been delegated primarily to local actors with limited decision-making mandates and possibilities to involve end users. The toolbox will support local actors with practical tools to co-create integrated services with and for older people.Plan for project realisationThe project will be conducted in collaboration between five Research and Development Units in Stockholm with partnering stakeholders in social services, primary care, and pensioner organizations. Costs for stakeholders’ involvement are included in the budget.

Research problem and specific questionsFalls among people with multiple sclerosis (PwMS) are common and lead to fear of falling, injuries, impaired health and high societal costs. Fall prevention interventions should focus on development of self-management skills and include non-ambulatory PwMS. We have, in a co-design process, developed a digital group based self-management fall prevention program. The aim is to evaluate this program. Research questions: 1) Is the fall prevention program effective in reducing number of falls in PwMS at 6- and 12-months post-intervention? 2) What contextual factors, mechanisms of impact and implementation aspects can likely explain the effects of the intervention? 3) How do PwMS experience their fall prevention behaviours and strategies in daily life at 6- and 12-months post-intervention?Data and methodThe program is evaluated in a randomized control trial regarding effect and process by quantitative and qualitative methods, in line with recommendation for complex interventions. Recruited are 208 PwMS, ambulatory and non-ambulatory, who are randomised to intervention or control. Number of falls are monitored from allocation until 12-months post-intervention via SMS dispatches. Primary effect outcome is fall incidence. Secondary outcomes include fall prevention behaviours, fear of falling, fall-related self-efficacy, physical activity, participation in daily activities, and impact of MS on health. Semi-structured interviews with a strategic selection of intervention PwMS and quantitative data from the program platform are used for process evaluation.Societal relevance and utilizationThe program contributes to reduce inequalities in care and rehabilitation for PwMS as the digital format gives PwMS living in communities without specialized MS-centres the opportunity to participate. The program’s focus on development of self-management skills contributes to increase social participation in PwMS, and if number of falls are reduced to decrease costs for the individual and the society.Plan for project realizationThe project is carried out by our interdisciplinary research group with expertise in quantitative and qualitative methods and MS. A PhD student will be recruited. Four trained group leaders will deliver the intervention during year 2024. Data are collected before randomization and immediately after and 6- and 12-months post-intervention. Costs are associated with project personnel (PhD student and researchers).

Home rehabilitation for older people is widely implemented, but research on the content and the effectiveness of the rehabilitation interventions used in practice are scarce and we lack of knowledge of how home-rehabilitation units collaborate with social- and health care services. The aim is to evaluate the state of home rehabilitation in relation to scientific evidence and the effectiveness on older persons’ well-being, participation and ability in daily activities as well as the older persons satisfaction with the interventions, the collaboration between social service- and health care providers, and level of service utilization. The design is based on the realist evaluation method, where a defined program theory is used as a base for the evaluation. The main characteristic is to identify context, mechanism and outcomes of the target process. The project will be conducted in Jönköping, Luleå and Stockholm which reflects different parts of the country in relation to size and care organisations. During phase 1, a program theory is established through systematic searches of scientific and grey literature

extracting data, analyzes and synthesizing will be conducted and discussed during four workshops. During phase 2, the context and mechanisms of impact is explored at home-rehabilitation units at the three sites, through observations of interaction between staff and patients, patient record auditing, and focus groups and interviews. During phase 3, the effectiveness of home rehabilitation will be evaluated by patient record auditing, register data, questionnaires and interviews and will be analyzed in relation to the described program theory. An overarching analysis of what, for whom and under which circumstances that home rehabilitation leads to change will be conducted with data from all three phases using mixed methods. The results of identified mechanisms and relevant context factors will be related to the outcomes of effectiveness to identify outcome patterns.

Older adults make up approximately 20% of the Swedish population. The ongoing demographic development, with an ageing population and a continuously larger proportion of older adults, leads to continuously increasing demand for appropriate and efficient geriatric care. One particularly critical moment in the continuum of care for older adults is the transition between different responsible authorities, between regional and municipal care.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.

As the population ages, the number of older people at risk for deterioration of health is expected to increase. This may imply decreased quality of life for the individual and rising costs for social and health care. As health is a far too complex area to be handled by one actor, this project targets collaboration in the welfare society to prevent deterioration of health. This includes the actors municipal social care, health care, the civic society, older adults, and relatives. There is a lack of research that takes a systems perspective of how to collaborate within and across organizations to prevent older adults’ deterioration of health. The aim is to investigate, co-design and evaluate models of collaborative prevention of deterioration of health among older adults living in the community. This will be conducted through a community-based participatory research in a multiple case study and explores:older adults’ use of social and health care, and which actors are involved or could be involved to achieve collaborative preventionwhat models of collaborative prevention is co-designed, and how collaboration is manifested in practicewhat agreed upon goals for collaboration are achieved, and what types of impact of collaborative prevention do actors identify as particularly significantin what ways the participatory research process influences actors and researchers, knowledge production and implementation of resultsThis project will produce innovative forms of collaboration to achieve effective coherent services that will help individuals maintain their health for as long as possible. The project’s both client and practice-oriented approaches will enable tailoring to local contexts and allow us to perform high-quality  research that is relevant for users and more easily integrated into everyday practice.