Extended Cross-sectoral Nurse Follow-up After Discharge From a Geriatric Ward - Benefits and Challenges. A Mixed-method Study

An appointment for a geriatric follow-up home visit is made with the patient and the municipal home care (community) nurse 2-4 days after discharge and only on weekdays. Relatives are informed about the visit and are welcome to join with the patient's acceptance. The local home care team as well as the patient's PCP receives the same digital discharge plan and discharge summary, respectively, as in the control group. While a follow-up visit is scheduled with the home care nurse, the PCP is invited to join too if available, either in person or by a video link. Administratively, the patients are treated as geriatric outpatients, with an in-home follow up instead of a visit in the Geriatric outpatient clinic.