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Table 1 The prioritised themes expressed by frail older patients and relatives going through a care transition from the hospital to their own home or rehabilitation centre

From: Involving frail older patients in identifying outcome measures for transitional care—a feasibility study

Headlines (prioritised by importance) Themes discussed by the expert panel Not actively prioritised by the expert panel
Care contents: overview and responsibility Health care personnel competency, options and drive: Granted services vs. the ability to deal with current individual needs Identify and solve practical challenges Number of carers/ health care professionals: too many/few/late/early/often or wrong profession    
Relatives: involvement in care decisions Involvement of the relatives during admission: consulting the relatives’ views Involvement in care planning: participating relatives, assigning tasks to the relatives Relatives taking an active part in the transition: being present at discharge Relieve burdens off relatives and avoidance of overloading Practically possible to be involved (time, place etc.)  
Care transition: overview, responsibility Manager/coordinator: to clarify and define responsibilities Knowledge about options, e.g., whom to contact in case of unforeseen events     Match care and treatment plan expectations to reach common agreement
Existential issues Existential and emotional considerations and reflections during admission, transition and after discharge      
Functional capacity, illness and disease Physical functional capacity and social capacity: regaining loss of function To return home     Diagnostic conclusion: to understand what happened
Culture       Cultural understanding Language barrier