References
- 1Lehnert T, Heider D, Leicht H, et al. Review: health care utilization and costs of elderly persons with multiple chronic conditions. Med Care Res Rev. 2011;68:387–420. DOI: 10.1177/1077558711399580
- 2WHO. World report on ageing and health. 2015.
- 3Health at a Glance 2021. OECD. Epub ahead of print 9 November 2021. DOI: 10.1787/ae3016b9-en
- 4Kern LM, Bynum JPW, Pincus HA. Care Fragmentation, Care Continuity, and Care Coordination—How They Differ and Why It Matters. JAMA Intern Med. 2024;184:236–237. DOI: 10.1001/jamainternmed.2023.7628
- 5Rocks S, Berntson D, Gil-Salmerón A, et al. Cost and effects of integrated care: a systematic literature review and meta-analysis. Eur J Heal Econ HEPAC Heal Econ Prev care. 2020;21:1211–1221. DOI: 10.1007/s10198-020-01217-5
- 6Alderwick H, Hutchings A, Briggs A, et al. The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews. BMC Public Health. 2021;21:753. DOI: 10.1186/s12889-021-10630-1
- 7Hedqvist A-T, Praetorius G, Ekstedt M. Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method. BMC Health Serv Res. 2023;23:851. DOI: 10.1186/s12913-023-09832-7
- 8Kodner DL. All together now: a conceptual exploration of integrated care. Healthc Q. 2009;13 Spec No: 6–15. DOI: 10.12927/hcq.2009.21091
- 9Suter E, Oelke ND, Adair CE, et al. Ten key principles for successful health systems integration. Healthc Q. 2009;13 Spec No: 16–23. DOI: 10.12927/hcq.2009.21092
- 10Johnson S, Bacsu J. Understanding complex care for older adults within Canadian home care: a systematic literature review. Home Health Care Serv Q. 2018;37:232–246. DOI: 10.1080/01621424.2018.1456996
- 11Tinetti ME, Fried TR, Boyd CM. Designing health care for the most common chronic condition – Multimorbidity. JAMA – J Am Med Assoc. 2012;307:2493–2494. DOI: 10.1001/jama.2012.5265
- 12Allison R
2nd , Assadzandi S, Adelman M. Frailty: Evaluation and Management. Am Fam Physician. 2021;103:219–226. - 13Church S, Rogers E, Rockwood K, et al. A scoping review of the Clinical Frailty Scale. BMC Geriatr. 2020;20:393. DOI: 10.1186/s12877-020-01801-7
- 14Collard RM, Boter H, Schoevers RA, et al. Prevalence of frailty in community-dwelling older persons: a systematic review. J Am Geriatr Soc. 2012;60:1487–1492. DOI: 10.1111/j.1532-5415.2012.04054.x
- 15Mesteig M, Helbostad JL, Sletvold O, et al. Unwanted incidents during transition of geriatric patients from hospital to home: a prospective observational study. BMC Health Serv Res. 2010;10:1. DOI: 10.1186/1472-6963-10-1
- 16Røsstad T, Garåsen H, Steinsbekk A, et al. Development of a patient-centred care pathway across healthcare providers: A qualitative study. BMC Health Serv Res; 13. Epub ahead of print 2013. DOI: 10.1186/1472-6963-13-121
- 17Duminy L, Ress V, Wild E-M. Complex community health and social care interventions – Which features lead to reductions in hospitalizations for ambulatory care sensitive conditions? A systematic literature review. Health Policy. 2022;126:1206–1225. DOI: 10.1016/j.healthpol.2022.10.003
- 18Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009;169:894–900. DOI: 10.1001/archinternmed.2009.71
- 19Dautzenberg L, Bretagne L, Koek HL, et al. Medication review interventions to reduce hospital readmissions in older people. J Am Geriatr Soc. 2021;69:1646–1658. DOI: 10.1111/jgs.17041
- 20Dimla B, Parkinson L, Wood D, et al. Hospital discharge planning: A systematic literature review on the support measures that social workers undertake to facilitate older patients’ transition from hospital admission back to the community. Australas J Ageing. 2023;42:20–33. DOI: 10.1111/ajag.13138
- 21Lillrank P. Integration and coordination in healthcare: an operations management view. J Integr Care. 2012;20:6–12. DOI: 10.1108/14769011211202247
- 22Schoen C, Osborn R, Squires D, et al. Frailty, gaps in care coordination, and preventable adverse events. J Popul Ageing. 2022;30:476.
- 23Melin Emilsson U, Strid A-L, Söderberg M. Lack of Coordination between Health Care and Social Care in Multi-Professional Teamwork – the Obstacle for Coherent Care of Older People Suffering from Multi-Morbidity. J Popul Ageing. 2022;15:319–335. DOI: 10.1007/s12062-020-09300-8
- 24Akinyelure OP, Colvin CL, Sterling MR, et al. Frailty, gaps in care coordination, and preventable adverse events. BMC Geriatr. 2022;22:476. DOI: 10.1186/s12877-022-03164-7
- 25Blakey EP, Jackson D, Walthall H, et al. What is the experience of being readmitted to hospital for people 65 years and over? A review of the literature. Contemp Nurse. 2017;53:698–712. DOI: 10.1080/10376178.2018.1439395
- 26Auerbach AD, Kripalani S, Vasilevskis EE, et al. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. JAMA Intern Med. 2016;176:484–493. DOI: 10.1001/jamainternmed.2015.7863
- 27Shuster C, Hurlburt A, Yung T, et al. Preventability of 28-Day Hospital Readmissions in General Internal Medicine Patients: A Retrospective Analysis at a Quaternary Hospital. Qual Manag Health Care. 2018;27:151–156. DOI: 10.1097/QMH.0000000000000174
- 28Auschra C. Barriers to the Integration of Care in Inter-Organisational Settings: A Literature Review. Int J Integr Care. 2018;18:5. DOI: 10.5334/ijic.3068
- 29Bhat K, Easwarathasan R, Jacob M, et al. Identifying and understanding the factors that influence the functioning of integrated healthcare systems in the NHS: a systematic literature review. BMJ Open. 2022;12:
e049296 . DOI: 10.1136/bmjopen-2021-049296 - 30Hughes G, Shaw SE, Greenhalgh T. Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts. Milbank Q. 2020;98:446–492. DOI: 10.1111/1468-0009.12459
- 31Threapleton DE, Chung RY, Wong SYS, et al. Integrated care for older populations and its implementation facilitators and barriers: A rapid scoping review. Int J Qual Heal Care. 2017;29:327–334. DOI: 10.1093/intqhc/mzx041
- 32Kodner DL, Spreeuwenberg C. Integrated care: Meaning, logic, applications, and implications – A discussion paper. Int J Integr Care; 2. DOI: 10.5334/ijic.67
- 33Schiøtz M, Price M, Frølich A, et al. Something is amiss in Denmark: a comparison of preventable hospitalisations and readmissions for chronic medical conditions in the Danish Healthcare system and Kaiser Permanente. BMC Health Serv Res. 2011;11:347. DOI: 10.1186/1472-6963-11-347
- 34Bäck MA. The norrtaelje model: A unique model for integrated health and social care in Sweden. Int J Integr Care; 15,
https://www.scopus.com/inward/record.uri?eid=2-s2.0-84948177128&partnerID=40&md5=0a5e0672202eede6cee6f9ad421ab705 (2015). - 35Huckfeldt PJ, Gu J, Escarce JJ, et al. The association of vertically integrated care with health care use and outcomes. Health Serv Res. 2021;56:817–827. DOI: 10.1111/1475-6773.13642
- 36Goddard M, Mason AR. Integrated Care: A Pill for All Ills? International journal of health policy and management. 2017;6:1–3. DOI: 10.15171/ijhpm.2016.111
- 37Ahgren B, Axelsson R. A decade of integration and collaboration: the development of integrated health care in Sweden 2000–2010. Int J Integr Care. 2011;11 Spec Ed:
e007 . DOI: 10.5334/ijic.566 - 38Liljas AEM, Brattström F, Burström B, et al. Impact of Integrated Care on Patient-Related Outcomes Among Older People – A Systematic Review. Int J Integr Care; 19. Epub ahead of print 2019. DOI: 10.5334/ijic.4632
- 39Dawson S, Kunonga P, Beyer F, et al. Does health and social care provision for the community dwelling older population help to reduce unplanned secondary care, support timely discharge and improve patient well-being? A mixed method meta-review of systematic reviews. F1000Research. 2020;9:857. DOI: 10.12688/f1000research.25277.1
- 40Rasmussen LF, Grode LB, Lange J, et al. Impact of transitional care interventions on hospital readmissions in older medical patients: a systematic review. BMJ Open. 2021;11:
e040057 . DOI: 10.1136/bmjopen-2020-040057 - 41Berntsen G, Strisland F, Malm-Nicolaisen K, et al. The Evidence Base for an Ideal Care Pathway for Frail Multimorbid Elderly: Combined Scoping and Systematic Intervention Review. J Med Internet Res. 2019;21:
e12517 . DOI: 10.2196/12517 - 42Baxter S, Johnson M, Chambers D, et al. The effects of integrated care: A systematic review of UK and international evidence. BMC Health Serv Res; 18. Epub ahead of print 2018. DOI: 10.1186/s12913-018-3161-3
- 43Van der Elst M, Schoenmakers B, Duppen D, et al. Interventions for frail community-dwelling older adults have no significant effect on adverse outcomes: a systematic review and meta-analysis. BMC Geriatr. 2018;18:249. DOI: 10.1186/s12877-018-0936-7
- 44Gonçalves-Bradley DC, Lannin NA, Clemson L, et al. Discharge planning from hospital. Cochrane database Syst Rev. 2022;2: CD000313. DOI: 10.1002/14651858.CD000313.pub6
- 45Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA.
Chapter 17: Intervention complexity . In: Cochrane Handbook for Systematic Reviews of Interventions version 6.4. Cochrane, 2023. - 46Damery S, Flanagan S, Combes G. Does integrated care reduce hospital activity for patients with chronic diseases? An umbrella review of systematic reviews. BMJ Open. 6. Epub ahead of print 2016. DOI: 10.1136/bmjopen-2016-011952
- 47Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff. 2008;27:759–769. DOI: 10.1377/hlthaff.27.3.759
- 48Kelly L, Harlock J, Peters M, et al. Measures for the integration of health and social care services for long-term health conditions: a systematic review of reviews. BMC Health Serv Res. 2020;20:358. DOI: 10.1186/s12913-020-05206-5
- 49Flanagan S, Damery S, Combes G. The effectiveness of integrated care interventions in improving patient quality of life (QoL) for patients with chronic conditions. An overview of the systematic review evidence. Health Qual Life Outcomes. 15. Epub ahead of print 2017. DOI: 10.1186/s12955-017-0765-y
- 50Chowdhury SR, Chandra Das D, Sunna TC, et al. Global and regional prevalence of multimorbidity in the adult population in community settings: a systematic review and meta-analysis. eClinicalMedicine. 57. Epub ahead of print 1 March 2023. DOI: 10.1016/j.eclinm.2023.101860
- 51Smith SL, Kathleen Pichora-Fuller M, Watts KL, et al. Development of the Listening Self-Efficacy Questionnaire (LSEQ). Int J Audiol. 2011;50:417–425. DOI: 10.3109/14992027.2011.553205
- 52Goncalves-Bradley DC, Lannin NA, Clemson LM, et al. Discharge planning from hospital. Cochrane database Syst Rev. 2016; CD000313. DOI: 10.1002/14651858.CD000313.pub5
- 53Verhaegh KJ, MacNeil-Vroomen JL, Eslami S, et al. Transitional care interventions prevent hospital readmissions for adults with chronic illnesses. Health Aff (Millwood). 2014;33:1531–1539. DOI: 10.1377/hlthaff.2014.0160
- 54Pigott T, Shepperd S. Identifying, documenting, and examining heterogeneity in systematic reviews of complex interventions. J Clin Epidemiol. 2013;66:1244–1250. DOI: 10.1016/j.jclinepi.2013.06.013
- 55Wells M, Williams B, Treweek S, et al. Intervention description is not enough: evidence from an in-depth multiple case study on the untold role and impact of context in randomised controlled trials of seven complex interventions. Trials. 2012;13:95. DOI: 10.1186/1745-6215-13-95
- 56Myndigheten för vård- och omsorgsanalys. Vården ur patienternas perspektiv – 65 år och äldre. En jämförelse mellan Sverige och tio andra länder. 2017.
- 57McGowan J, Sampson M, Salzwedel DM, et al. PRESS Peer Review of Electronic Search Strategies: 2015 Guideline Statement. J Clin Epidemiol. 2016;75:40–46. DOI: 10.1016/j.jclinepi.2016.01.021
- 58Booth A, Moore G, Flemming K, et al. Taking account of context in systematic reviews and guidelines considering a complexity perspective. BMJ Glob Heal. 2019;4:
e000840 . DOI: 10.1136/bmjgh-2018-000840 - 59Munn Z, Stern C, Aromataris E, et al. What kind of systematic review should I conduct? A proposed typology and guidance for systematic reviewers in the medical and health sciences. BMC medical research methodology. 2018;18:5. DOI: 10.1186/s12874-017-0468-4
- 60Berntsen GKR, Dalbakk M, Hurley JS, et al. Person-centred, integrated and pro-active care for multi-morbid elderly with advanced care needs: a propensity score-matched controlled trial. BMC Health Serv Res. 2019;19:682. DOI: 10.1186/s12913-019-4397-2
- 61Thygesen LC, Fokdal S, Gjorup T, et al. Can municipality-based post-discharge follow-up visits including a general practitioner reduce early readmission among the fragile elderly (65+ years old)? A randomized controlled trial. Scand J Prim Health Care. 2015;33:65–73. DOI: 10.3109/02813432.2015.1041831
- 62Belur J, Tompson L, Thornton A, et al. Interrater Reliability in Systematic Review Methodology: Exploring Variation in Coder Decision-Making. Sociol Methods Res. 2018;50:837–865. DOI: 10.1177/0049124118799372
- 63Higgins JPT, Li T, Deeks JJ.
Chapter 6: Choosing effect measures and computing estimates of effect in Cochrane Handbook for Systematic Reviews of Interventions . In: Cochrane Handbook for Systematic Reviews of Interventions version 6.4 (updated August 2023). Cochrane,https://training.cochrane.org/handbook/current/chapter-06 (2023). - 64Cochrane Effective Practice and Organisation of Care. Suggested risk of bias criteria for EPOC reviews. Resources for review authors. 2017.
- 65Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA.
Chapter 12: Synthesizing and presenting findings using other methods . In: Cochrane Handbook for Systematic Reviews of Interventions Version 6.4. Cochranee, 2023. - 66Buurman BM, Parlevliet JL, Allore HG, et al. Comprehensive geriatric assessment and transitional care in acutely hospitalized patients the transitional care bridge randomized clinical trial. JAMA Intern Med. 2016;176:302–309. DOI: 10.1001/jamainternmed.2015.8042
- 67Cordato NJ, Kearns M, Smerdely P, et al. Management of Nursing Home Residents Following Acute Hospitalization: efficacy of the “Regular Early Assessment Post-Discharge (REAP)” Intervention. J Am Med Dir Assoc. 2018;19:276.e11–276.e19. DOI: 10.1016/j.jamda.2017.12.008
- 68Røsstad T, Salvesen Ø, Steinsbekk A, et al. Generic care pathway for elderly patients in need of home care services after discharge from hospital: a cluster randomised controlled trial. BMC Health Serv Res. 2017;17:1–9. DOI: 10.1186/s12913-017-2206-3
- 69Sahota O, Pulikottil-Jacob R, Marshall F, et al. The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency. Age Ageing. 2016;46:26–32. DOI: 10.1093/ageing/afw149
- 70Wong FK, Ho MM, Yeung S, et al. Effects of a health-social partnership transitional program on hospital readmission: a randomized controlled trial. Soc Sci Med. 2011;73:960–969. DOI: 10.1016/j.socscimed.2011.06.036
- 71Meyer AM, Bartram MP, Antczak P, et al. A Tailored Discharge Program Improves Frailty and Mood in Patients Undergoing Usual Rehabilitative Care: A Randomized Controlled Trial. J Am Med Dir Assoc. 2022;23:1962.e1–1962.e13. DOI: 10.1016/j.jamda.2022.09.003
- 72Sorensen A, Grotts JF, Tseng C-H, et al. A Collaboration Among Primary Care–Based Clinical Pharmacists and Community-Based Health Coaches. J Am Geriatr Soc. 2021;69:68–76. DOI: 10.1111/jgs.16839
- 73Jenq GY, Doyle MM, Belton BM, et al. Quasi-Experimental Evaluation of the Effectiveness of a Large-Scale Readmission Reduction Program. JAMA Intern Med. 2016;176:681–690. DOI: 10.1001/jamainternmed.2016.0833
- 74Crilly J, Chaboyer W, Wallis M, et al. An outcomes evaluation of an Australian Hospital in the Nursing Home admission avoidance programme. J Clin Nurs. 2011;20:1178–1187. DOI: 10.1111/j.1365-2702.2010.03371.x
- 75Robert B, Sun AH, Sinden D, et al. A Case-Control Study of the Sub-Acute Care for Frail Elderly (SAFE) Unit on Hospital Readmission, Emergency Department Visits and Continuity of Post-Discharge Care. J Am Med Dir Assoc. 2021;22:544. DOI: 10.1016/j.jamda.2020.07.020
- 76Watson A, Charlesworth L, Jacob R, et al. The Community In-Reach and Care Transition (CIRACT) clinical and cost-effectiveness study: study protocol for a randomised controlled trial. Trials. 2015;16:41. DOI: 10.1186/s13063-015-0551-2
- 77Pfadenhauer LM, Gerhardus A, Mozygemba K, et al. Making sense of complexity in context and implementation: the Context and Implementation of Complex Interventions (CICI) framework. Implement Sci. 2017;12:21. DOI: 10.1186/s13012-017-0552-5
- 78Drucker AM, Fleming P, Chan A-W. Research Techniques Made Simple: Assessing Risk of Bias in Systematic Reviews. J Invest Dermatol. 2016;136:e109–e114. DOI: 10.1016/j.jid.2016.08.021
- 79Lewis S, Damarell RA, Tieman JJ, et al. Finding the Integrated Care Evidence Base in PubMed and Beyond: A Bibliometric Study of the Challenges. Int J Integr Care. 2018;18:11. DOI: 10.5334/ijic.3975
- 80Joober R, Schmitz N, Annable L, et al. Publication bias: what are the challenges and can they be overcome? Journal of psychiatry & neuroscience: JPN. 2012;37:149–152. DOI: 10.1503/jpn.120065
- 81Kristiansson RS, Ssegonja R, Ropponen A, et al. Introduction of specialized heart failure nurses in primary care and its impact on readmissions. Prim Health Care Res Dev. 2022;23:
e78 . DOI: 10.1017/S1463423622000676