ABSTRACT
Hospitals and municipalities expect their healthcare personnel to conform to different values and professional traditions. Hospitals focus on treatment, whereas municipalities focus on care, function and coping. These different tasks are performed separately, rather than in collaboration, even when such collaboration would be the best solution for the patient (Danielsen and Fjær 2010; Glouberman and Mintzberg 2001). Many studies have revealed the lack of coordination when discharging older patients from hospital to home as a significant problem (Aase et al. 2013; Dahl et al. 2014; Laugaland et al. 2011, 2012). Hospital discharge is a critical phase in patient recovery, and shorter hospital stays and rapid discharge require coordination between health personnel across organisations to ensure adequacy of services and to avoid readmissions (Storm et al. 2014). Elderly patients with both physical and cognitive health challenges represent a significant proportion of health service users in both hospitals and municipalities. Because Norway has a twofold healthcare system and because the two services have different legally mandated tasks, it will be these elderly patients who are most often moved between hospital and municipality health services (Tjora and Tøndel 2012). Coordination of health services is essential for these patients to receive proper treatment and care.
