Table 1 Overview of the included studies

Andreasen, 2015 [22]

Denmark

Interviews

1 week after discharge

Primary to secondary

Tilburg Frailty Indicator + comorbidity

Acutely admitted frail elderly

80.6, {69–93}

“was to explore how the frail elderly experience daily life 1 week after discharge from an acute admission to the hospital”

Arendts, 2015 [21]

Australia

Interviews

When resident were able to do the interview

Secondary to primary

Unclear*

Residents of Residential Aged Care facilities (RACF)

88

“to capture and interpret the perspectives of three important decision-making groups concerning the transfer of residents from RACF to Emergency department; to understand how the perspectives of these converge and diverge; and to explore shared decision-making and the extent to which there was delegation of transfer decisions to others”

Bayliss, 2008 [23]

USA

Interviews

Unclear

Secondary

Three target conditions (diabetes, depression, osteoarthritis) + self-reported condition

Members of a not- for-profit Health Maintenance Organization

(65–84)

“was to explore patient perspectives on components of ‘best’ Processes of care for persons with multiple morbidities in order to inform the development of future interventions to improve care”

Butterworth, 2014 [24]

United Kingdom

Interviews

Unclear

Secondary

14 participants had one or more chronic diseases

Registered with surgery for at least 6 month

(65–74),

(75–84),

(85–94)

“to investigate the association between older patients’ trust in their general practitioner and their perceptions of shared decision-making.”

Foss, 2011 [25]

Norway

Face to face questionnaire

2–3 weeks after discharge

Primary to secondary

Unclear*

Patients discharged from hospitals

86.9 +/− 4.9

“was to describe older hospital patients’ discharge experiences concerning participation in discharge planning”

Gabrielsson-Järhult, 2016 [26]

Sweden

Observations and discharge meeting material

Before discharge

Primary to secondary

Unclear*

Admitted to hospital and about to be discharged

81

“was to explore older people’s concerns about their needs as expressed in a discharge planning meeting at a hospital”

Gill, 2014 [27]

Canada

Interviews

Unclear

Primary to secondary

Two or more chronic conditions

Patients from a family health team

82.3 +/− 7.7

“was to explore the challenges experienced by 27 patients-caregivers-family physician triads in an attempt to capture a full understanding of their health system experience and to illuminate where system improvements are most needed for managing multimorbidity”

Neiterman, 2015 [28]

Canada

Interviews

2–5 weeks post discharge

Primary to secondary

Lace score 10 or higher

Patients discharged from acute care hospital

(70–89)

“was to understand how patients and their caregivers experienced the transition to community and which barriers and facilitators they identified on their way to recovery”

Sheaff, 2017 [29]

United Kingdom

Interviews

May 2012–November 2013

Primary to secondary

Two or more specified chronic conditions

Patient who had been admitted within a year and who had received care from 2 separate healthcare services

78, (65 or older)

“was to analyze what information was changed or lost in communication between clinicians and a group of frail older patients in England, and some implications for care coordination and continuity”