Frail elderly people refer to multi-diseased and vulnerable patients in need of medication and healthcare. These patients require healthcare from several different healthcare organizations, including hospital care, primary care, and municipal care services. This situation is challenging the capacity of healthcare organizations to manage inter-professional collaboration for person-centered care. This paper aims to identify challenges associated with collaboration between different healthcare organizations, related to the use of IT systems in the daily work practice. The paper was based on a qualitative study, which included three focus group interviews, each lasting for two hours. Each focus group consisted of a hospital physician, a primary care physician, a hospital nurse, a primary care nurse, a municipal home care nurse or an assistant officer, a physical or occupational therapist, and a family member representative. The interviews were analyzed with thematic analysis. Challenges identified in the study include insufficient information exchange, inconsistencies in communication, differences in the use of IT systems, and deficient coordination. The work processes that aim to promote collaboration between different healthcare organizations need to be better organized, and the use of IT systems needs to be better aligned.
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