Trajectories of care needs and care transitions after age 60: the interplay between individuals’ frailty, their environment, and personal perspectives

This project aims at increasing our knowledge concerning care needs and patterns of care utilization of frail and clinically complex older adults, to identify timely actions towards a more proactive and integrated healthcare.

An increased rate of transition of frail individuals between healthcare (primary care, hospital) and social care providers (home care services, institutions) has been observed but not well characterized. At the same time, fragmented and idiosyncratic care transitions are arguably responsible for a quicker functional decline, which accelerates frailty development. Finally, patients’ perspectives and experiences have been rarely taken into consideration when designing care paths, especially when frailty is at play.

Taking advantage of three well-characterized Swedish population-based studies part of the Swedish National Study on Aging and Care (SNAC), and of the National E-Infrastructure on Aging Research (NEAR) we will analyze data of over 7,000 individuals 60+, living in both urbanized and rural areas of four different Regions.

We plan to develop three interconnected subprojects having the following aims:

1. To characterize seniors’ care transition patterns while considering their underlying clinical conditions, frailty, and the availability of formal and informal social care
2. To quantify the impact of unplanned and avoidable healthcare episodes, and the fast transition through different care settings, on the clinical trajectories and frailty
3. To better understand patients’ experiences and preferences in relation to their history of healthcare utilization and care transition episodes, while considering their clinical and frailty trajectories.

Through this project, we expect to identify relevant risk profiles and harmful care utilization patterns as a basis for more integrated and person-centered care, which hopefully will delay or postpone frailty, reduce morbidity burden, and improve patients’ experiences and quality of life.

Researchers participating in the project

Davide Liborio Vetrano, Laura Fratiglioni, Debora Rizzuto, Amaia Calderón-Larrañaga, Anders Wimo, Anders Sköldunger, Johan Sanmartin Berglund, Åsa Hedberg Rundgren

Timeline

2021-2025