Background: Transitional care for older chronically ill people is an important area for healthcare quality improvement. A central goal is to involve older people more in transitional care and make care more patient-centered. Recently, asking, "What matters to you?" (WMTY) has become a popular way of approaching the implementation of patientcentered care. The aim of this study was to explore health care providers' perceptions and experiences regarding the question of WMTY in the context of improving transitional care for older, chronically ill persons. Methods: The data comprise semi-structured individual interviews with 20 health care providers (HCPs) who took part in a Norwegian quality improvement collaborative, three key informant interviews, and observations of meetings in the quality improvement collaborative. We used a thematic analysis approach. Results: Three interrelated themes emerged from the analysis: WMTY is a complex process that needs to be framed competently; framing WMTY as a functional approach; and framing WMTY as a relational approach. There was a tension between the functional and the relational approach. This tension seemed to be based in different understandings of the purpose of asking the WMTY question and the responsibility that comes with asking it. Conclusions: WMTY may appear as a simple question, but using it in everyday practice is a complex process, which requires professional competence. When seen in terms of a patient-centered goal process, the challenge of competently eliciting older people's personal goals and transferring these goals into professional action becomes evident. An important factor seems to be how HCPs regard the limits of their responsibility in relation to giving care within the larger frame of the patient's life project. Factors in the organizational and political context also seem to influence substantially how HCPs approach older patients with the WMTY question.

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Geriatric patients in intermediate care (IC) often do not feel involved in their rehabilitation process. We conducted interviews with 15 patients and 12 relatives to explore their experiences and preferences regarding patient participation in IC and identify types of patient participation and their potential empowering or disempowering effect. The analysis disclosed a lack of patient choice in a predetermined IC pathway. Being deserving of help meant being sick enough and was associated with the compliant patient who fits the system. Some main additional features were the need of a rehabilitation perspective and patient engagement to enable coproduction as well as the important contribution of relatives as advocates and allies. Finally, the results show the patients’ vulnerable voice in the meeting with the experts’ views. The study will add important knowledge on how staff can contribute to the tailoring of good interventions in IC and improve the understanding of underlying structures.

Background Improving the transitional care of older people, especially hospital-to-home transitions, is a salient concern worldwide. Current research in the field highlights person-centered care as crucial; however, how to implement and enact this ideal in practice and thus achieve more person-centered patient pathways remains unclear. The aim of this study was to explore health care providers’ (HCPs’) perceptions and experiences of what is important to achieve more person-centered patient pathways for older people. Methods This was a qualitative study. We performed individual semistructured interviews with 20 HCPs who participated in a Norwegian quality improvement collaborative. In addition, participant observation of 22 meetings in the quality improvement collaborative was performed. Results A thematic analysis resulted in five themes which outline central elements of the HCPs’ perceptions and experiences relevant to achieving more person-centered patient pathways: 1) Finding common ground through the mapping of the patient journey; 2) the importance of understanding the whole patient pathway; 3) the significance of getting to know the older patient; 4) the key role of home care providers in the patient pathway; and 5) ambiguity toward checklists and practice implementation. Conclusions The findings can assist stakeholders in understanding factors important to practicing person-centered transitional care for older people. Through collaborative knowledge sharing the participants developed a more shared understanding of how to achieve person-centered patient pathways. The importance of assuming a shared responsibility and a more holistic understanding of the patient pathway by merging different ways of knowing was highlighted. Checklists incorporating the What matters to you? question and the mapping of the patient journey were important tools enabling the crossing of knowledge boundaries both between HCPs and between HCPs and the older patients. Home care providers were perceived to have important knowledge relevant to providing more person-centered patient pathways implying a central role for them as knowledge brokers during the patient’s journey. The study draws attention to the benefits of focusing on the older patients’ way of knowing the patient pathway as well as to placing what matters to the older patient at the heart of transitional care.