Health and social care planning in collaboration in older persons' homes: the perspectives of older persons, family members and professionals.

Providing health and social care to older persons is challenging, since older persons often have multiple diseases and a complex health situation. Hence many professions and organisations are involved. Lack of interprofessional and interorganisational collaboration leads to fragmented care. Care planning meetings before hospital discharge have long been used to overcome this fragmentation, but meetings conducted at the hospital have limitations in identifying long-term needs at home. A new model for health and social care planning in collaboration (HSCPC) in older persons' homes was introduced in two Swedish municipalities. The aim of this study was to gain a deeper understanding of the HSCPC-meeting from the perspectives of older persons, family members, and professionals. Ten care planning meetings from two municipalities were consecutively included. Interviews in retrospect with ten older persons, eight family members, and ten groups of professionals who had attended the HSCPC-meeting at home were analysed with a hermeneutic approach. Four themes emerged: unspoken agendas and unpreparedness, security and enhanced understanding, asymmetric relationships, and ambiguity about the mission and need for follow-up. The comprehensive interpretation is that the professionals handled the HSCPC-meeting mainly as a routine task, while the older persons and family members viewed it as part of their life course. Older persons are in an inferior institutional, cognitive and existential position. However, meeting together in the home partly reduced their inferior position. Findings from this study provide some general suggestions for how HSCPC-meetings should be designed and developed: attention of power relations, the importance of meeting skills and follow-up.