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Continuum of care for frail older people - from the acute ward to home

The aim of this study was to create a continuum of care for frail older people, from the acute ward to their own home. It was conducted as a randomised controlled trial with two study arms (1).

The study was conducted in several steps; 1) pre-studies with a comprehensive review of the current scientific knowledge in the field, 2) using the knowledge base to develop a model for continuum of care together with care organisations, 3) evaluating an RCT in parallel with studying the model in an implementation study (2). The data collection finished in November 2011.

The study has resulted in work methods for better continuity when frail older people seek acute care. The work method supports older people to maintain their independence and self-determination in their own homes. Moreover, the study showed that integrated care doubled the chances of being independent in ADL for up to 12 months when compared to a control group.

Consequently, the intervention could support frail older people to age well at home, a benefit for both the older people themselves and for the society (3). The work method has resulted in implemented care and support organisers in the community, screening and geriatric competence at acute wards, and care planning is now being conducted in the older persons’ own homes by collaboration across organisations.


(1) Wilhelmson K, Dunér A, Eklund K, Gosman-Hedström G, Blomberg S, Hasson H, Gustafsson H, Landahl S, Dahlin-Ivanoff S. Continuum of care for frail elderly people: Design of a randomized controlled study of a multi-professional and multidimensional intervention targeting frail elderly people. BMC Geriatr 2011;11:24

(2) Hasson H, Blomberg S, Dunér A. Fidelity and moderating factors in complex interventions: a case study of a continuum of care program for frail elderly people in health and social care Implementation Science 2012; 7:23

(3) Eklund K, Wilhelmson K, Gustafsson H, Landahl S, Dahlin-Ivanoff S. One-year outcome of frailty indicators and activities of daily living following the randomised controlled trial; "continuum of care for frail older people". BMC Geriatr 2013;13(1)


Zarah Ebrahimi ”Frail elders´experiences of health. A combination of qualitative and quantitative studies with a salutogenic perspective”

Helene Berglund ”Quality in the continuum of care for frail older persons - Structure, process and outcome

Isabelle Ottenvall-Hammar ”Navigating towards a self-determined daily life in old age. Experiences, instrument evaluation and explanatory factors

Christina Ekelund ”Att vara agent i sitt eget liv - Hur självbestämmande kan förstås, uppfattas och utvärderas i en kontext av sköra äldre personer


Synneve Dahlin-Ivanoff, Kajsa Eklund, Katarina Wilhelmsson, Eva Holmgren, Anna Duner, Eva Liden, Sten Landahl.


Page Manager: Josefin Bergenholtz|Last update: 2/11/2019

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