Bakgrund: Befolkningen i Sverige blir allt äldre och äldre personer med komplexa vårdbeho vökar. År 2014 var cirka 500000 personer 80 år eller äldre i Sverige och detta beräknas öka till 800000 år 2030. Allt fler äldre vårdas i ordinärt boende och många av dem har komplexa vårdbehov som kräver vård både från landsting, primärvård och kommunal hälso-och sjukvård. Av den anledningen är samarbetet mellan dessa verksamheter en avgörande faktor för att omvårdnaden ska uppnå den kvalitet som de äldre med komplexa vårdbehov har rätt till. Specialistsjuksköterskorfrån de olika verksamheterna har här en viktig roll och det är en utmaning både för denne men även övrig vårdpersonal. Syfte: Syftet med studien är att beskriva specialistsjuksköterskors erfarenheter av samarbete mellan verksamheter i omvårdnaden av äldre med komplexa vårdbehov. Metod: Kvalitativ innehållsanalys med induktiv ansats användes för att kunna besvara studiens syfte. Sju intervjuer genomfördes med både specialistsjuksköterskor och sjuksköterskor som arbetade inom primärvård eller kommunal hälso- och sjukvård. Intervjuerna spelades in, transkriberades och analys gjordes enligt Graneheim och Lundman (2004). Resultat: I resultatet framkom att samarbete mellan olika verksamheter är komplex. Det framkom många faktorer som försvårar vården av den äldre med komplexa vårdbehov och det krävs engagemang och vilja från all vårdpersonal för att samarbetet ska fungera. Slutsats: Personcentrerad vård har stor betydelse för samarbetet mellan verksamheter i omvårdnaden av äldre med komplexa vårdbehov. Att bedriva ett samarbete mellan verksamheter är komplex och flera faktorer påverkar hur det fungerar. / Background: The population in Sweden is getting older and the number of olderpeople is increasing with complex care needs. In 2014, approximately 500,000 people were80 years or older in Sweden and this is estimated to increase to 800,000 by 2030. More and more older people are being cared for in ordinary housing and many of them have complex care needs that require care from county councils, primary care and municipal health and healthcare. For this reason, the collaboration between these activities is a decisive factor for the nursing to achieve the quality to which the older with complex care needs are entitled. Specialist nurses from the various activities have an important role and it is a challenge both for them but also for other care staff. Aim: The aim of this study is to describe specialist nurses’/nurses’ experience of collaboration between establishments in nursing care of older people with complex care needs. Method: Qualitative content analysis with inductive approach was used to answer the aim of the study. Seven interviews were conducted with both specialist nurses and nurses working in primary care or municipal health care. The interviews were recorded, transcribed, and analyzed according to Graneheim and Lundman (2004). Results: The results showed that collaboration between different activities is complex. Many factors emerged that make it more difficult to care for the older with complex care needs. The commitment and willingness of all care staff is required for the collaboration to work. Conclusion: Person-centered care is of great importance for the collaboration between activities in the care of the older with complex care needs. Conducting a collaboration between establishments is complex and several factors affect how it works.

Bakgrund Andelen äldre personer ökar i Sverige och den grupp bland äldre som ökar mest är över 90 år. Antalet äldre som är i behov av vård- och omsorgsinsatser från både socialtjänsten och hälso- och sjukvård förväntas därmed också öka. Ökad efterfrågan på kommunal hjälp i hemmet ställer höga krav på god samverkan och kommunikation mellan de olika instanserna för att minska risken för brister och vårdskador hos den äldre personen med komplexa vårdbehov. Komplexa vårdbehov innebär samtidig närvaro av förändringar som kommer av åldrandet, multisjuklighet, polyfarmaci och skörhet. Syfte Syftet med studien var att undersöka sjuksköterskors erfarenhet av kommunikation kring den äldre patienten med komplexa vårdbehov inom den kommunala hälso- och sjukvården. Metod Studien var en kvalitativ intervjustudie med induktiv ansats. Deltagarna i studien arbetade inom kommunal hälso- och sjukvård i två sydsvenska kommuner. Sex av deltagarna var grundutbildade sjuksköterskor, tre av deltagarna var distriktssjuksköterskor och en var specialistsjuksköterska inom vård av äldre. Datan som samlats in analyserades med hjälp av kvalitativ innehållsanalys. Resultat Resultatet ledde fram till tre huvudkategorier och sju underkategorier. Huvudkategorierna var Samverkan och dialog, Organisatoriska förutsättningar samt Utbildning, Språk och Kompetens. En nära relationen till omvårdnadspersonalen, rätt kompetens och erfarenhet hos omvårdnadspersonalen samt regelbundna möten och träffar var faktorers som ansågs underlätta kommunikationen. Slutsats  Sjuksköterskorna beskrev att teamsamverkan med planerade teamträffar och fysiska möten med personalen var viktigt för fungerande kommunikation. Att minska distansen mellan personalen och ha fungerande rutiner kring kommunikationen var andra värdefulla aspekter som framkom. Det som ansågs försvåra kommunikationen var stress och tidsbrist samt brister i språket hos omvårdnadspersonalen men även organisatoriska hinder så som dålig täckning på mobiltelefoner, laghinder och bristande kontinuitet hos omvårdnadspersonalen. / Background  The proportion of elderly people is increasing in Sweden, and the group among the elderly that is increasing the most is over 90 years of age. The number of elderly people who need care and care interventions from both social services and health care is therefore also expected to increase. Increased demand for municipal help in the home places high demands on good cooperation and communication between the various agencies to reduce the risk of deficiencies and care injuries in the elderly person with complex care needs. Complex care needs mean the simultaneous presence of changes that come from aging, multimorbidity, polypharmacy and frailty. Purpose The purpose of the study was to investigate nurses' experience of communication regarding the elderly patient with complex care needs within the municipal health care system.  Method The study was a qualitative interview study with an inductive approach. The participants in the study worked in municipal health care in two municipalities in southeast of Sweden. Six of the participants were basic nurses, three of the participants were district nurses and one was a specialist nurse in the care of the elderly. The data collected was analyzed using qualitative content analysis. Results The result led to three main categories and seven subcategories. The main categories were Collaboration and dialogue, Organizational conditions and Education, Language and Competence. A close relationship with the nursing staff, the right skills and experience of the nursing staff and regular meetings were considered to facilitate communication. Conclusion  The nurses described that team cooperation with planned team meetings and physical meetings with the staff was important for effective communication. Reducing the distance between staff and having working routines around communication were other valuable aspects that emerged. What was considered to make communication difficult was stress and lack of time as well as deficiencies in the language of the nursing staff, but also organizational obstacles such as poor mobile phone coverage, legal obstacles and a lack of continuity among the nursing staff.

Background: Previous studies have shown that an integrated care approaches for older people with complex care needs comes with less hospitalization and the reduced cost for the community (Eklund & Wilhelmssons, 2009). Since the new reform about coordinated care (2017:612) took place higher demand was put on the professionals in the health care system to collaborate. The reform indicates that a coordinated care plan should be establish to people with complex care needs when they go from in- to outpatient care (SKR, 2018) Aim: To describe health professionals in municipality, institutional care and primary experience of coordinated care plans to older people with complex care needs and describe their opinion of which elements that facilitated and embarrass the process.Method: The study was conducted whit a qualitative study design in form of interviews. Nine respondents were included in the study. A content analysis with a deductive approach was used (Elo & Kyngäs’s. 2018). Widmarks et al; s (2011) model was used as a theoretical framework.Result: The key factors: allocation of responsibilities, confidence and the professional encounter was found in the analyses. And there were areas in al of them were barriers to collaboration occurred and made collaboration difficult. Conclusion: The result indicates that there is a lack of clarity due to the guidelines of the collaboration process. These guidelines must be improved to facilitate collaboration for older people with complex care needs.

One of the central challenges for the healthcare system today is how to manage care for patients with complex needs. This patient group is not well-defined but covers patients with serious diseases and comorbidities, or with a limited ability to perform basic daily functions due to physical, mental or psychosocial challenges. This group has a high service and resource utilisation resulting in high costs for the healthcare system and, typically, poor health outcomes. To improve care for these patients, it is necessary to implement strategies to manage the differentiated care needs, the additional support needs, the uncertainty in care delivery, and the coordination needs of the involved providers and the patient. Care pathways are increasingly used internationally to make care more patient-centred and to structure and design care processes for individual patient groups. Important elements in care pathways include structuring care activities, by defining their content and sequence; coordinating between providers and professionals; and involving patients in their care process. In this thesis, care pathways are proposed as the overall strategy for managing care for patients with complex care needs. The purpose of this thesis is thus to contribute with knowledge on how care pathways can be managed for patients with complex care needs. This is achieved by analysing how the practices coordination, standardisation, customisation and personalisation can support management of care pathways and by discussing how these practices influence quality of care. The quality of care dimensions discussed are accessible, timely, equitable, and patient-centred care. The empirical context in this thesis is the Standardised Cancer Care Pathways (CCPs) which were implemented in Sweden from 2015 to 2018. CCPs is the umbrella term for the national initiative to shorten waiting times, decrease regional differences and reduce fragmentation in care processes. CCPs include elements such as diagnosis-specific pathways and guidelines, introduction of CPP coordinators, and mandatory reporting of waiting times. Focus has been on implementing care pathways for 31 cancer diagnoses in all Swedish healthcare regions. Both qualitative and quantitative research methods have been used. A case study was conducted to examine standardised and customised care pathways, and coordination and multidisciplinary work in care pathways. A document study of regional reports on CCPs was analysed to study effects of care pathways on accessibility, timeliness and equitability. Finally, a national survey was conducted to deepen the understanding of the role of coordination, as performed by coordinators, in care pathways. This thesis argues that standardised and customised care pathways should be combined to manage care for patients with complex care needs. The customised pathway in particular benefits patients with serious unspecific symptoms, unknown primary tumour or more complex care needs, while patients with care needs that can be treated independently of the main diagnosis benefit from following a standardised care pathway. Coordinators are an important means to manage coordination, customisation and personalisation in the care pathway. The coordinators’ role is twofold: the first role is to manage care pathways by customising the care pathway and coordinating involved providers; the second role is to support and guide patients through the care pathway. This can be achieved by adapting interpersonal communication with patients through personalisation. This thesis further argues that care pathways have most potential to positively influence accessibility, timeliness, equitability, and patient-centredness. Accessibility has been positively influenced, especially for patients with ambiguous symptoms where symptoms indicating cancer have improved their chances of accessing cancer diagnostics. A negative aspect of prioritising patients who follow CCPs has been the potentially longer waiting times for other patient groups in equal need of urgent care. Notwithstanding, prioritised access to care is perceived to positively influence timeliness for patients following CCPs. Care pathways are perceived to have positively influenced patient-centredness by shifting the focus from what to deliver to how to deliver it.