Janne Agerholm

Research problem and specific questions Sweden’s population is ageing, and the prevalence of multimorbidity and functional limitations is increasing. This puts strong demands on effective coordination between health and social care. The Coordinated Individual Plan (CIP) is intended as a tool to ensure better coordination between health and social care providers. However, previous evaluations show uneven implementation and unclear effects of CIP. This project aims to identify factors that facilitate or hinder CIP implementation, and analyse its impact on healthcare utilisation and costs. The study will also examine differences in access to CIPs based on sociodemographic factors, with the goal of contributing to more equitable care. Finally, concrete strategies will be developed to translate the research findings into actionable recommendations for care practice. Data and methods The project applies a multi-method design. Qualitative interviews with older adults and their relatives will explore experiences of receiving a CIP after discharge. Focus groups with both regional and municipal professionals will identify challenges and best practices for achieving good coordination. Register-based analyses will investigate effects on healthcare utilisation and costs, as well as differences between population groups. In addition, co-creation workshops with staff, decision-makers, and user organisations will be used to develop practical strategies for strengthening the use of CIPs. Societal relevance and utilisation By clarifying barriers and facilitators for the implementation of CIP and analysing its outcomes, the project provides knowledge that can be used to develop more person-centred, equitable, and efficient care. Co-creation workshops with stakeholders will ensure that results are translated into guidelines, training, and new working methods, making them directly applicable in the ongoing transformation towards God och nära vård (care closer to home). Plan for project realisation The project will run for four years and be conducted by an interdisciplinary team with expertise in health services research, social gerontology, epidemiology, and health economics. An advisory board of practitioners and user representatives will be closely involved. Results will be disseminated through scientific and popular science publications, policy briefs, and seminars, with the overall aim of strengthening coordination and improving care for older adults with complex needs.