Transitions from Hospital to Long-Term Care (completed)

This project has three main foci: patient flow, user perspectives, and inter-agency barriers

About the project

This project is a national multi-centre study in collaboration with Gjøvik University College (HiG), Norwegian Social Research (NOVA) and SINTEF Health.


In Norway there are structural and organisational differences between primary and secondary (e.g. hospital) health care provision. Yet, the two sectors interface continuously as individuals move in and out of each sector. Patients moving from hospitals to long-term primary health care are generally considered to be a major source of coordination problems.

Elderly patients are especially important in this respect. This group has a pattern of hospital service use that differs markedly from other age groups. Rates of admission have increased markedly the past ten years; length of stay has fallen comparatively; and the problem of rehospitalisation is increasing. Previous research suggests that improving inter-agency cooperation in health care yields major gains in terms of patient satisfaction, costs, medical outcomes and the frequency of rehospitalisation.

However, knowledge is sparse in terms of the characteristics of patient flow across the hospital and long-term sectors among persons 80 years and above.

The data gathering for the project was concluded in June 2009. The material consists of both quantitative and qualitative data. It includes personal interviews with 254 patients 80 years and older from 67 municipalities in Norway discharged from 14 hospitals. In addition 262 next of kin of the patients were interviewed via telephone. Altogether the existing empirical material consists of 516 interviews associated with 330 patient discharges from hospital.


The main focus of the project is on the process of patients moving from hospitals to long-term primary health care. The aim of the project is to expand knowledge in three areas:

  1. Patient flow: the total patient flow from all types of hospitals into home care and nursing home care in the municipalities will be investigated.
  2. User perspectives: this covers participation, information and evaluation of the processes related to the transition process as experienced by patients 80+ and their primary caregivers.
  3. Inter-agency barriers:  are there factors connected to care systems, professionals or patients that lead to major deficiencies for participants during the transition process?

The Group for Elderly Care Research (GEOF) is involved in all three phases, but has the major responsibility for Part two, user perspectives.




  • Norwegian Research Council (NFR)


  • Gjøvik University College (HiG)
  • Norwegian Social Research (NOVA) 
  • SINTEF Health

Start - Finish


Published Apr. 8, 2011 8:49 AM - Last modified Feb. 9, 2022 12:20 PM


Christina Foss

Project leader

Tor Inge Romøren (HiG & NOVA)


Detailed list of participants