LAUSR

AIM To outline and discuss care transitions and care continuity following hospital discharge of older people with complex care needs in three Nordic cities: Copenhagen, Tampere and Stockholm. METHODS Data on potential pathways following hospital discharge of older people were obtained from existing literature and expert consultations. The pathways for each system were outlined and presented in three figures. The hospital discharge process of the systems was then compared. RESULTS In all three care systems, the main care path from hospital is to home. Short-term intermediate healthcare can be provided in all three systems, possibly creating additional care transitions; however, once home, extensive home healthcare may prevent further care transitions. Opportunities for continuity of care include needs assessments (all cities) and meetings with the patient about care upon return home (Copenhagen, Stockholm). Yet this is challenged by lack of transfer of information (Tampere) and patients' having to apply for some services themselves (Tampere, Stockholm). CONCLUSIONS Comparisons of the discharge processes studied suggest that despite individual care planning and short- and long-term care options, transitional care and care continuity are challenged by limited access as some services need to be applied for by the older person themselves.