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About 50% of patients with cancer are expected to need radiotherapy (RT), and the majority of these are older. To improve outcomes for older patients with cancer, geriatric assessment (GA) with management (GAM) is highly recommended. Evidence for its benefits is still scarce, in particular for patients receiving RT. We report the protocol of a cluster-randomised pilot study designed to test the effect, feasibility and health economic impact of a GAM intervention for patients ≥65 years, referred for palliative or curative RT. The randomising units are municipalities and city districts. The intervention is municipality-based and carried out in collaboration between hospital and municipal health services from the start of RT to eight weeks after the end of RT. Its main constituents are an initial GA followed by measures adapted to individual patients' impairments and needs, systematic symptom assessments and regular follow-up by municipal cancer nurses, appointed to coordinate the patient's care. Follow-up includes at least one weekly phone call, and a house call four weeks after the end of RT. All patients receive an individually adapted physical exercise program and nutritional counselling. Detailed guidelines for management of patients' impairments are provided. Patients allocated to the intervention group will be compared to controls receiving standard care. The primary outcome is physical function assessed by the European Organisation of Research and Treatment of Cancer Quality of Life Questionnaire C-30. Secondary outcomes are global quality of life, objectively tested physical performance and use of health care services. Economic evaluation will be based on a comparison of costs and effects (measured by the main outcome measures). Feasibility will be assessed with mixed methodology, based on log notes and questionnaires filled in by the municipal nurses and interviews with patients and nurses. The study is carried out at two Norwegian RT centres. It was opened in May 2019. Follow-up will proceed until June 2022. Statistical analyses will start by the end of 2021. We expect the trial to provide important new knowledge about the effect, feasibility and costs of a GAM intervention for older patients receiving RT. Trial registration: ClinTrials.gov, ID NCT03881137, initial release 13th of March 2019. The study is made possible by the Dam Foundation (grants number ref 19-3656) via the Norwegian Cancer Society (ref. 247593001) (both Norwegian non-profit organisations), Innlandet Hospital Trust (grant number 150406), the Liaison Committee for Education, Research and Innovation in Central Norway (grant number 19/4740-3), and The Joint Research Committee between St. Olav's hospital and the Faculty of Medicine and Health Sciences, NTNU – The Norwegian University of Science and Technology (FFU) (grant number 2018/42795).

Background Studies regarding adequacy of secondary stroke prevention are limited. We report medication adherence, risk factor control and factors influencing vascular risk profile following ischaemic stroke. Methods A total of 664 home‐dwelling participants in the Norwegian Cognitive Impairment After Stroke study, a multicenter observational study, were evaluated 3 and 18 months poststroke. We assessed medication adherence by self‐reporting (4‐item Morisky Medication Adherence Scale) and medication persistence (defined as continuation of medication(s) prescribed at discharge), achievement of guideline‐defined targets of blood pressure (BP) (

Et av hovedmålene i samhandlingsreformen har vært at kommuner i samarbeid med sykehus skal kunne tilby helhetlige og integrerte tjenester før og etter sykehusopphold, basert på sammenhengende pasientforløp. Kommuner og foretak er derfor i den nye helse- og omsorgsloven blitt pålagt å inngå forpliktende samarbeidsavtaler om innleggelse og utskrivning av pasienter. Vi har fulgt noen sykehus og kommuner som sammen har forsøkt å utvikle helhetlige pasientforløp for KOLS, hjertesvikt, slag og hoftebrudd som også omfattet oppfølging i kommunen. Vi finner at spesialisering av tjenester og personell i primærhelsetjenesten for oppfølging av spesifikke diagnoser hverken er bærekraftig eller funksjonelt. I tillegg vil det å forlenge diagnosespesifikke forløp fra sykehus ut i kommunen bidra til fragmentering av tjenestene til eldre og kronisk syke. I noen av kommunene ble det utviklet og tatt i bruk generisk diagnoseuavhengige forløp. Det fungerte for disse kommunene og framstår som en mer bærekraftig modell. Nøkkelord: Samhandling, behandlingslinje, kommunehelsetjeneste, hjemmesykepleie, utskrivningsklare pasienter, multisyke pasienter. Helhetlige pasientforløp – gjennomføring i primærhelsetjenesten

Objective: To explore the feasibility of disease-specific clinical pathways when used in primary care. Design: A mixed-method sequential exploratory design was used. First, merging and exploring quality interview data across two cases of collaboration between the specialist care and primary care on the introduction of clinical pathways for four selected chronic diseases. Secondly, using quantitative data covering a population of 214,700 to validate and test hypothesis derived from the qualitative findings. Setting: Primary care and specialist care collaborating to manage care coordination. Results: Primary-care representatives expressed that their patients often have complex health and social needs that clinical pathways guidelines seldom consider. The representatives experienced that COPD, heart failure, stroke and hip fracture, frequently seen in hospitals, appear in low numbers in primary care. The quantitative study confirmed the extensive complexity among home healthcare nursing patients and demonstrated that, for each of the four selected diagnoses, a homecare nurse on average is responsible for preparing reception of the patient at home after discharge from hospital, less often than every other year. Conclusions: The feasibility of disease-specific pathways in primary care is limited, both from a clinical and organisational perspective, for patients with complex needs. The low prevalence in primary care of patients with important chronic conditions, needing coordinated care after hospital discharge, constricts transferring tasks from specialist care. Generic clinical pathways are likely to be more feasible and efficient for patients in this setting.Key pointsClinical pathways in hospitals apply to single-disease guidelines, while more than 90% of the patients discharged to community health care for follow-up have multimorbidity. Primary care has to manage the health care of the patient holistically, with all his or her complex needs.Patients most frequently admitted to hospitals, i.e. patients with COPD, heart failure, stroke and hip fracture are infrequent in primary care and represent a minority among patients in need of coordinated community health care.In primary care, the low rate of receiving patients discharged from hospitals of major chronic diseases hampers maintenance of required specific skills, thus constricting the transfer of tasks to primary care. Generic clinical pathways are suggested to be more feasible than disease-specific pathways for most patients with complex needs.

Background Improved discharge arrangements and targeted post-discharge follow-up can reduce the risk of adverse events after hospital discharge for elderly patients. Although more care is to shift from specialist to primary care, there are few studies on post-discharge interventions run by primary care. A generic care pathway, Patient Trajectory for Home-dwelling elders (PaTH) including discharge arrangements and follow-up by primary care, was developed and introduced in Central Norway Region in 2009, applying checklists at defined stages in the patient trajectory. In a previous paper, we found that PaTH had potential of improving follow-up in primary care. The aim of this study was to establish the effect of PaTH—compared to usual care—for elderly in need of home care services after discharge from hospital. Methods We did an unblinded, cluster randomised controlled trial with 12 home care clusters. Outcomes were measured at the patient level during a 12-month follow-up period for the individual patient and analysed applying linear and logistic mixed models. Primary outcomes were readmissions within 30 days and functional level assessed by Nottingham extended ADL scale. Secondary outcomes were number and length of inpatient hospital care and nursing home care, days at home, consultations with the general practitioners (GPs), mortality and health related quality of life (SF-36). Results One-hundred and sixty-three patients were included in the PaTH group (six clusters), and 141 patients received care as usual (six clusters). We found no statistically significant differences between the groups for primary and secondary outcomes except for more consultations with the GPs in PaTH group (p = 0.04). Adherence to the intervention was insufficient as only 36% of the patients in the intervention group were assessed by at least three of the four main checklists in PaTH, but this improved over time. Conclusions Lack of adherence to PaTH rendered the study inconclusive regarding the elderly’s functional level, number of readmissions after hospital discharge, and health care utilisation except for more consultations with the GPs. A targeted exploration of prerequisites for implementation is recommended in the pre-trial phase of complex intervention studies. Trial registration Clinical Trials.gov NCT01107119, retrospectively registered 2010.04.18. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2206-3) contains supplementary material, which is available to authorized users.

The need for integration of healthcare services and collaboration across organisational boundaries is highlighted as a major challenge within healthcare in many countries. Care pathways are often presented as a solution to this challenge. In this article, we study a project of developing, introducing and using a care pathway across healthcare levels focusing on older home-dwelling patients in need of home care services after hospital discharge. In so doing, we use the concept of boundary object, as described by Star and Griesemer, to explore how care pathways can act as tools for translation between specialist healthcare services and home care services. Based on interviews with participants in the project, we find that response to existing needs, local tailoring, involvement and commitment are all crucial for the care pathway to function as a boundary object in this setting. Furthermore, the care pathway, as we argue, can be used to push boundaries just as much as it can be used as a tool for bridging across them, thus potentially contributing to a more equal relationship between specialist healthcare services and home care services. © 2015. This is the authors' accepted and refereed manuscript to the article. The final authenticated version is available online at: http://journals.sagepub.com/doi/10.1177/1363459314567789

Background: Different models for care pathways involving both specialist and primary care have been developed to ensure adequate follow-up after discharge. These care pathways have mainly been developed and run by specialist care and have been disease-based. In this study, primary care providers took the initiative to develop a model for integrated care pathways across care levels for older patients in need of home care services after discharge. Initially, the objective was to develop pathways for patients diagnosed with heart failure, COPD and stroke. The aim of this paper is to investigate the process and the experiences of the participants in this developmental work. The participants were drawn from three hospitals, six municipalities and patient organizations in Central Norway. Methods: This qualitative study used focus group interviews, written material and observations. Representatives from the hospitals, municipalities and patient organizations taking part in the development process were chosen as informants. Results: The development process was very challenging because of the differing perspectives on care and different organizational structures in specialist care and primary care. In this study, the disease perspective, being dominant in specialist care, was not found to be suitable for use in primary health care because of the need to cover a broader perspective including the patient’s functioning, social situation and his or her preferences. Furthermore, managing several different disease-based care pathways was found to be unsuitable in home care services, as well as unsuitable for a population characterized by a substantial degree of comorbidity. The outcome of the development process was a consensus that outlined a single, common patient-centred care pathway for transition from hospital to follow-up in primary care. The pathway was suitable for most common diseases and included functional and social aspects as well as disease follow-up, thus merging the differing perspectives. The disease-based care pathways were kept for use within the hospitals. Conclusions: Disease-based care pathways for older patients were found to be neither feasible nor sustainable in primary care. A common patient-centred care pathway that could meet the needs of multi- morbid patients was recommended. Keywords: Care coordination, Continuity of patient care, Healthcare disparities, Multi-morbidity, Patient discharge, Primary care, Home care services, Interdisciplinary communication, Organizational culture, Health services for the aged. © 2013 Røsstad et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Geriatric patients recently discharged from hospital experience increased chance of unplanned readmissions and admission to nursing homes. Several studies have shown that medication-related discrepancies are common. Few studies report unwanted incidents by other factors than medications. In 2002 an ambulatory team (AT) was established within the Department of Geriatrics, St. Olavs University Hospital HF, Trondheim, Norway. The AT monitored the transition of the patients from hospital to home and four weeks after discharge in order to reveal unwanted incidents. The aim of the present study was to describe unwanted incidents registered by the AT among patients discharged from a geriatric evaluation and management unit (GEMU) by character, frequency and stage in the transitional process. Only unwanted incidents with a severity making contact with the primary health care (PHC) necessary were registered. Methods: A prospective observational study with patients treated in the GEMU and followed by the AT was performed. Current practice included comprehensive geriatric assessment and management including discharge planning in the GEMU and collaboration with the primary health care on appointments on assistance to be provided after discharge from hospital. Unwanted incidents severe enough to induce contact with the primary health care were registered during the transitional phase and after discharge. Results: 118 patients (65% female), with mean age 83.2 ± 6.4 years participated. Median Barthel Index at discharge was 18 (interquartile range 16-19) and median Mini Mental Status Examination 24 (interquartile range 21-26). A total of 146 unwanted incidents were registered in 70 (59%) of the patients. Most frequent were unwanted incidents related to drug prescription regime (32%), exchange of information in and between the GEMU and the primary health care (25%) and service or help provided from the PHC (17%). Conclusions: Despite a seemingly well-organised system for transition of patients from the GEMU to their homes, one or more unwanted incidents occurred in most patients during discharge or four weeks post discharge. The study has revealed areas of importance for improving transitional care of geriatric patients. © 2010 Mesteig et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.