Balancing Standardisation and Individualisation in Transitional Care Pathways: A Meta-Ethnography of the Perspectives of Older Patients, Informal Caregivers and Healthcare Professionals

Introduction: The EU-funded SELFIE framework defines integrated care as “structured efforts to provide coordinated, pro-active, person-centred, multidisciplinary care by two or more well-communicating and collaborating care providers either within or across sectors”. For frail, older patients with complex health issues, high-quality transitions are especially important as these patients typically move more frequently within healthcare settings, requiring treatment from different providers. Nevertheless, despite efforts to improve quality in transitional care, research indicates that there is a lack of clear guidance to deal with practical challenges that may arise, and many older people are ‘falling through the gaps’ and experiencing fragmented healthcare. Aim and Methods: We aimed to synthesise older patients, informal caregivers and healthcare professionals’ experiences and preferences of challenges to achieving high-quality transitional care. We used the seven-step method for meta-ethnography originally developed by Noblit and Hare. Based on twelve articles we incorporated the experiences and preferences of geriatric patients, informal caregivers and healthcare professionals from four separate but interlinked qualitative projects (https://uni.oslomet.no/crosscareold/): 1) nutritional care in the transitions between specialist and primary care, 2) patient participation in intermediate care services, 3) quality of hospital healthcare and 30 days after discharge and 4) experiences from a Norwegian quality improvement collaborative. Results: Quality transitional care reflects a dedication to provide the best care to patients and their informal caregivers, as well as a commitment to the team and the organisational culture. We identified dilemmas that occur due to conflicting policies expressing various domains of the quality concept in transitional care for older persons and their informal caregivers, which implies balancing standardisation and individualisation in transitional geriatric care pathways. To provide high-quality transitional care, we identified that the healthcare system must be balanced with respect to i) person-centred and efficient care, ii) how the care team approaches everyday patient life while treating the illness, iii) translating what matters to patients into users’ choices and iv) relational versus practical care skills among healthcare professionals. Balancing these potential dilemmas must be addressed at all levels, including the policy, organisational and individual levels to obtain person-centred pathways. Conclusions: Our findings provide a comprehensive understanding of the tensions between different discourses. Incorporating a certain professional flexibility within the wider boundary of standardisation may give staff the necessary room for negotiation to meet patient values and needs while ensuring patient flow and values such as equity and evidence-based practice. Implications: The study conveys extended knowledge about the practice of transitional care from the perspectives of older patients, informal caregivers and staff and will be of relevance for researchers, clinicians, politicians, and other important stakeholders in healthcare to inform the development, implementation, and evaluation of transitional care in the future.