1.Plothner M, Schmidt K, de Jong L, Zeidler J, Damm K: Needs and preferences of informal caregivers regarding outpatient care for the elderly: a systematic literature review. BMC Geriatr 2019, 19(1).
2.Calvó-Perxas L, Vilalta-Franch J, Litwin H, Turró-Garriga O, Mira P, Garre-Olmo: What seems to matter in public policy and the health of informal caregivers? A cross-sectional study in 12 European countries. Josep PLoS ONE 2018, 13(3):e0194232.
3.Schulz R, Eden J: Families caring for an aging America: National Academies Press Washington, DC; 2016.
4.Carpentier N, Bernard P, Grenier A, Guberman N: Using the life course perspective to study the entry into the illness trajectory: The perspective of caregivers of people with Alzheimer’s disease. Soc Sci Med 2010, 70(10):1501–1508.
5.Gibbons SW, Ross A, Bevans M: Liminality as a Conceptual Frame for Understanding the Family Caregiving Rite of Passage: An Integrative Review. Res Nurs Health 2014, 37(5):423–436.
6.Peacock SC, Hammond-Collins K, Forbes DA: The journey with dementia from the perspective of bereaved family caregivers: a qualitative descriptive study.(Report). BMC Nurs 2014, 13(1).
7.Penrod J, Hupcey JE, Shipley PZ, Loeb SJ, Baney B: A Model of Caregiving Through the End of Life: Seeking Normal. West J Nurs Res 2012, 34(2):174–193.
8.National Academies of Sciences E, Medicine: Families caring for an aging America: National Academies Press; 2016.
9.Reinhard SC, Feinberg LF: The escalating complexity of family caregiving: Meeting the challenge. In: Family caregiving in the new normal. edn.: Elsevier; 2015: 291–303.
10.Barbabella F, Poli A, Andréasson F, Salzmann B, Papa R, Hanson E, Efthymiou A, Döhner H, Lancioni C, Civerchia P et al: A Web-Based Psychosocial Intervention For Family Caregivers Of Older People: Results From A Mixed-Methods Study In Three European Countries. In.: Zenodo; 2016.
11.Anker-Hansen C, Skovdahl K, McCormack B, Tønnessen S: The third person in the room: The needs of care partners of older people in home care services-A systematic review from a person- centred perspective. J Clin Nurs 2018, 27(7–8):e1309-e1326.
12.WHO: Handbook for national quality policy and strategy - A practical approach for developing policy and strategy to improve quality of care [updated 2018; cited 28.10.2019]
13.Batalden P: Getting more health from healthcare: quality improvement must acknowledge patient coproduction. BMJ Open 2018, 362:k3617.
14.Rydeman I, Törnkvist L, Agreus L, Dahlberg K: Being in-between and lost in the discharge process—An excursus of two empirical studies of older persons’, their relatives’, and care professionals’ experience. International Journal of Qualitative Studies on Health and Well-being 2012, 7(1).
15.Aasen EM, Kvangarsnes M, Heggen K: Nurses’ perceptions of patient participation in hemodialysis treatment. Nurs Ethics 2012, 19(3):419–430.
16.WHO: World report on aging and health. [cited 2019 Oct 29]. Available from: https://www.who.int/ageing/events/world-report–2015-launch/en/ (2015).
17.CLARKE A, Rosen RJ: Length of stay: How short should hospital care be? Eur J Public Health 2001, 11(2):166–170.
18.Kroneman M, Siegers JJ, medicine: The effect of hospital bed reduction on the use of beds: a comparative study of 10 European countries. Soc Sci Med, 2004, 59(8):1731–1740.
19.Galvin EC, Wills T, Coffey A: Readiness for hospital discharge: A concept analysis. J Adv Nurs 2017, 73(11):2547–2557.
20.Spehar AM, Campbell RR, Cherrie C, Palacios P, Scott D, Baker JL, Bornstad B, Wolfson J,: Seamless Care: Safe Patient Transitions From Hospital to Home. In. Agency For Healthcare R, Quality Rockville MD 2005.
21.Deniger A, Troller P, Kennelty KA: Geriatric transitional care and readmissions review. The Journal for Nurse Practitioners 2015, 11(2):248–252.
22.Krumholz HM: Post-hospital syndrome—an acquired, transient condition of generalized risk. N Engl J Med 2013, 368(2):100–102.
23.Storm M, Siemsen IMD, Laugaland K, Dyrstad DN, Aase K: Quality in transitional care of the elderly: Key challenges and relevant improvement measures. International Journal of Integrated Care 2014, 14:e013.
24.Lanièce I, Couturier P, Dramé M, Gavazzi G, Lehman S, Jolly D, Voisin T, Lang PO, Jovenin N, Gauvain JBJA et al: Incidence and main factors associated with early unplanned hospital readmission among French medical inpatients aged 75 and over admitted through emergency units. 2008, 37(4):416–422.
25.Gusmano M, Rodwin V, Weisz D, Cottenet J, Quantin C: Comparison of rehospitalization rates in France and the United States. J Health Serv Res Policy 2015, 20(1):18–25.
26.Lum HD, Studenski SA, Degenholtz HB, Hardy S: Early hospital readmission is a predictor of one-year mortality in community-dwelling older Medicare beneficiaries. J Gen Intern Med 2012, 27(11):1467–1474.
27.Dramé M, Lang P, Novella J-L, Narbey D, Mahmoudi R, Laniece I, Somme D, Gauvain J-B, Heitz D, Voisin T: Six-month outcome of elderly people hospitalized via the emergency department: the SAFES cohort. European Geriatric Medicine 2012, 60(3):189–196.
28.Jencks SF, Williams MV, Coleman EA: Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009, 360(14):1418–1428.
29.Carey K, Lin M-Y: Readmissions to New York hospitals fell for three target conditions from 2008 to 2012, consistent with Medicare goals. Health Aff 2015, 34(6):978–985.
30.Hvalvik S, Reierson IÅ: Striving to maintain a dignified life for the patient in transition: Next of kin’s experiences during the transition process of an older person in transition from hospital to home. International Journal of Qualitative Studies on Health and Well-being 2015, 10(1).
31.Noest S, Ludt S, Klingenberg A, Glassen K, Heiss F, Ose D, Rochon J, Bozorgmehr K, Wensing M, Szecsenyi J: Involving patients in detecting quality gaps in a fragmented healthcare system: development of a questionnaire for Patients’ Experiences Across Healthcare Sectors (PEACS). Int J Qual Healthcare 2014, 26(3):240–249.
32.CROSSCARE-OLD [cited 2019 Oct 29]. Available from: https://blogg.hioa.no/crosscareold
33.Johnson B, Christensen LB: Educational research: quantitative, qualitative, and mixed approaches, 4th ed. edn. Los Angeles, Calif: Sage; 2012.
34.Malterud K: Qualitative research: standards, challenges, and guidelines. The Lancet 2001, 358(9280):483–488.
35.Van Manen M: Researching lived experience: Human science for an action sensitive pedagogy: Routledge; 2016.
36.Creswell JW, Creswell JD: Research design: qualitative, quantitative & mixed methods approaches, 5th edition. edn. Los Angeles, California: Sage; 2018.
37.Grbich C: Qualitative data analysis: an introduction, 2nd ed. edn. London: Sage; 2013.
38.Hand DJ: Qualitative Inquiry in Clinical and Educational Settings by Danica G. Hays, Anneliese A. Singh. International Statistical Review 2013, 81(1):167–168.
39.Tong A, Sainsbury P, Craig J: Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Healthcare 2007, 19(6):349–357.
40.The Norwegian Healthcare System [cited 2019 Oct 29]. Available from: https://international.commonwealthfund.org/countries/norway/]
41.Holm S, Mathisen T, Saeterstrand T, Brinchmann B: Allocation of home care services by municipalities in Norway: a document analysis. BMC Health Services Research 2017, 17.
42.Creswell JW, Poth CN: Qualitative inquiry & research design: choosing among five approaches, Fourth edition. edn. Los Angeles: SAGE; 2018.
43.Creswell JW, Plano Clark VL: Designing and conducting mixed methods research, 3rd ed. edn. Los Angeles: Sage; 2018.
44.Baztan JJ, Suarez-Garcia FM, Lopez-Arrieta J, Rodriguez-Manas L, Rodriguez-Artalejo F: Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis.(Report). Br Med J 2009, 338(7690):334.
45.Morse JM: Designing funded qualitative research. InN. K. Denzin & YS Lincoln (Eds.), Handbook of qualitative research (pp. 220–235). In.: Thousand Oaks, CA: Sage Publications; 1994.
46.Malterud K, Siersma VD, Guassora AD: Sample Size in Qualitative Interview Studies: Guided by Information Power. Qual Health Res 2016, 26(13):1753–1760.
47.Braun V, Clarke V: Using thematic analysis in psychology. Qualitative research in psychology 2006, 3(2):77–101.
48.Holloway I, Todres L: The status of method: flexibility, consistency and coherence. Qualitative research 2003, 3(3):345–357.
49.Braun V, Clarke V: What can “thematic analysis” offer health and wellbeing researchers? International Journal of Qualitative Studies on Health and Well-being 2014, 9(1).
50.Lincoln YS, Guba EG: Naturalistic inquiry. Beverly Hills, Calif: Sage; 1985.
51.Bryman A: Social research methods, 5th ed. edn. Oxford: Oxford University Press; 2016.
52.Patton MQ: Qualitative research & evaluation methods: integrating theory and practice, 4th ed. edn. Los Angeles, Calif: Sage; 2015.
53.Hirschman KB, Shaid E, McCauley K, Pauly MV, Naylor MD: Continuity of Care: The Transitional Care Model. Online J Issues Nurs 2015, 20(3):1.
54.Abu-Rish Blakeney E, Lavallee DC, Baik D, Pambianco S, O’Brien KD, Zierler BK: Purposeful interprofessional team intervention improves relational coordination among advanced heart failure care teams. Journal of Interprofessional Care 2019, 33(5):481–489.
55.Heidi G, Astri S: Earlier hospital discharge: a challenge for Norwegian municipalities. Nordic Journal of Social Research 2017, 8.
56.Holmås TH, Islam MK, Kjerstad E: Between two beds: inappropriately delayed discharges from hospitals. International journal of healthcare finance and economics 2013, 13(3–4):201–217.
57.Simmonds RL: Factors influencing professional decision making on unplanned hospital admission: a qualitative study. Br J Gen Pract 2012, 62(604):e750-e756.
58.OECD: Health at a Glance 2017; 2017.
59.Suwan N, Panuthai S, Lasuka D, Khampolsiri T: Factors Influencing Readiness for Hospital Discharge Among Thai Older Persons with Chronic Obstructive Pulmonary Disease. Pacific Rim International Journal of Nursing Research 2018, 22(2):156–168.
60.Watts R, Gardner H, Pierson J: Factors that enhance or impede critical care nurses’ discharge planning practices. Intensive Crit Care Nurs 2005, 21(5):302–313.
61.Dusek B, Pearce N, Harripaul A, Lloyd M: Care Transitions: A Systematic Review of Best Practices. Journal of Nursing Care Quality 2015, 30(3):233–239.
62.Finset A: Emotions, narratives and empathy in clinical communication. International journal of integrated care 2010, 10 Suppl(Suppl):e020.
63.McCormack B, Skatvedt A: Older people and their care partners’ experiences of living with mental health needs: a focus on collaboration and cooperation. J Clin Nurs 2017, 26(1–2):103–114.
64.Benten J, Spalding NJQiA, Adults O: Intermediate care: what are service users’ experiences of rehabilitation? 2008, 9(3):4–14.
65.Trappes-Lomax T, Hawton A: The user voice: older people’s experiences of reablement and rehabilitation. Journal of Integrated Care 2012, 20(3):181–195.
66.Dyrstad DN, Testad I, Aase K, Storm M: A review of the literature on patient participation in transitions of the elderly. Cognition, Technology & Work 2015, 17(1):15–34.
67.McCormack B, McCance T: Person-centred practice in nursing and healthcare: theory and practice, Second edition. edn. Chichester: Wiley-Blackwell; 2017.
68.Gaugler J, Kane RL: Family Caregiving in the New Normal. Burlington: Elsevier Science; 2015.
69.Campbell H, Hotchkiss R, Bradshaw N, Porteous M: Integrated care pathways. BMJ 1998, 316(7125):133–137.
70.Leijten FRM, Struckmann V, van Ginneken E, Czypionka T, Kraus M, Reiss M, Tsiachristas A, Boland M, de Bont A, Bal R et al: The SELFIE framework for integrated care for multi-morbidity: Development and description. Health Policy 2018, 122(1):12–22.
71.Levenstein JH, McCracken EC, McWhinney IR, Stewart MA, BROWN JB: The patient-centred clinical method. 1. A model for the doctor-patient interaction in family medicine. Fam Pract 1986, 3(1):24–30.
72.Eklund JH, Holmström IK, Kumlin T, Kaminsky E, Skoglund K, Höglander J, Sundler AJ, Condén E, Meranius MS: “Same same or different?” A review of reviews of person-centered and patient-centered care. Patient Educ Couns 2018, 102(1): 3–11.
73.Batalden PB, Davidoff F: What is “quality improvement” and how can it transform healthcare? In.: BMJ Publishing Group Ltd; 2007.
74.Stockdale SE, Zuchowski J, Rubenstein LV, Sapir N, Yano EM, Altman L, Fickel JJ: Fostering evidence-based quality improvement for patient-centered medical homes: Initiating local quality councils to transform primary care.(Report)(Author abstract). Healthcare Manage Rev 2018, 43(2):168.
75.Saini V, Garcia-Armesto S, Klemperer D, Paris V, Elshaug AG, Brownlee S, Ioannidis JPA, Fisher ES: Drivers of poor medical care. The Lancet 2017, 390(10090):178–190.
76.Murray R, Caulier-Grice J, Mulgan G: The open book of social innovation: National endowment for science, technology and the art London; 2010.
77.Pinquart M, Sörensen S, Sciences S: Correlates of physical health of informal caregivers: a meta-analysis. J Gerontol B Psychol Sci Soc Sc 2007, 62(2):P126-P137.
78.Carretero S, Garcés J, Ródenas F, Sanjosé V: The informal caregiver’s burden of dependent people: Theory and empirical review. Arch Gerontol Geriatr 2009, 49(1):74–79.
79.Korpi W, Palme J: The paradox of redistribution and strategies of equality: Welfare state institutions, inequality, and poverty in the western countries. Am Sociol Rev 1998, 63(5):661–687.