title: Quality in transitional care of the elderly: Key challenges and relevant improvement measures.
abstract: BACKGROUND
  Elderly people aged over 75 years with multifaceted care needs are often in need of hospital treatment. Transfer across care levels for this patient group increases the risk of adverse events. The aim of this paper is to establish knowledge of quality in transitional care of the elderly in two Norwegian hospital regions by identifying issues affecting the quality of transitional care and based on these issues suggest improvement measures.
  
  
  METHODS
  Included in the study were elderly patients (75+) receiving health care in the municipality admitted to hospital emergency department or discharged to community health care with hip fracture or with a general medical diagnosis. Participant observations of admission and discharge transitions (n = 41) were carried out by two researchers.
  
  
  RESULTS
  SIX MAIN CHALLENGES WITH BELONGING DESCRIPTIONS HAVE BEEN IDENTIFIED: (1) next of kin (bridging providers, advocacy, support, information brokering), (2) patient characteristics (level of satisfaction, level of insecurity, complex clinical conditions), (3) health care personnel's competence (professional, system, awareness of others' roles), (4) information exchange (oral, written, electronic), (5) context (stability, variability, change incentives, number of patient handovers) and (6) patient assessment (complex clinical picture, patient description, clinical assessment).
  
  
  CONCLUSIONS
  Related to the six main challenges, several measures have been suggested to improve quality in transitional care, e.g. information to and involvement of patients and next of kin, staff training, standardisation of routines and inter-organisational staff meetings.
authors.affiliation: Department of Health Studies, University of Stavanger, Stavanger, Norway.
authors.forename: Marianne
authors.initials: M
authors.lastname: Storm
authors.affiliation: The Capital Region of Denmark, Centre for Health, Copenhagen, Denmark.
authors.forename: Inger Margrete D
authors.initials: IM
authors.lastname: Siemsen
authors.affiliation: Health Trust Førde, Førde, Norway.
authors.forename: Kristin
authors.initials: K
authors.lastname: Laugaland
authors.affiliation: Department of Health Studies, University of Stavanger, Stavanger, Norway.
authors.forename: Dagrunn Nåden
authors.initials: DN
authors.lastname: Dyrstad
authors.affiliation: Department of Health Studies, University of Stavanger, Stavanger, Norway.
authors.forename: Karina
authors.initials: K
authors.lastname: Aase
keywords: elderly; participant observations; patient handover; quality; transitional care