Frail older persons are recognized as an especially vulnerable patient group. They are dependent on coordinated and integrated healthcare efforts, provided by healthcare professionals from hospitals, primary care and municipal care. The increasing number of older persons with complex illnesses, and shorter inpatient care, calls for provision of care closer to home and emphasizes the need for collaboration between healthcare providers (Dahl et al., 2014), especially in connection with discharge from inpatient care, which is regulated by law in Sweden (SFS 2017:612).Discharge from hospital implies a transition of care from one site to another. Such a transition can make the transferred persons extra vulnerable, especially frail older persons with multiple health problems, and can result in fragmented care, medication errors, medical complications and dissatisfaction among professionals, patients or their relatives (Elliott et al., 2018;Newnham et al., 2017).Therefore, a coordinated individual care plan (CIP) is utilized to plan