A collaborative chain out of phase: the organization of tasks and information needed in the process of discharging a care-needing older patient from hospital to municipal care

PURPOSE: To understand the needs of information in the collaboration between health personnel in hospitals and care nursing personnel in municipal care in the process of discharging care-needing older patients from hospitals. THEORY: The analytical perspective is a process of patient transition, in which responsible actors in health and municipal care have to collaborate in certain patterns, within a tight time schedule, restricted by the different organizational framework of a hospital or a municipality within which individual actors are situated. METHODS: Step 1: Qualitative studies with nursing personnel in six municipalities and nurses in the hospitals serving the actual municipalities. Step 2: A survey addressed to key informants in municipal care in a representative sample of Norwegian municipalities. RESULTS: The formal routines of information exchange associated with these kinds of discharges are too slow and out of phase with informational needs. Seventy percent of our respondent stated that information delivered through formal routines had already been collected by informal contacts. Formal routines were usually weakest for patients to be taken care of in their own homes—where the need for information in many cases was greater than for patients going to local institutions.