Mapping collaboration and coordination of health and care services for older people with dementia: A scoping review
Open accessAbstract
Responsibility for health and care services for people with dementia is often divided between various professionals, agencies, and authorities, causing a fragmentation of care and an unclear division of responsibility between different stakeholders. In relation to this, collaboration and coordination of health and care services are often described as vital for catering to diverse needs and to provide adequate support. The aim of this scoping review was to map how different health and care agencies collaborate and coordinate services for older people with dementia. Joanna Briggs Institute’s proposed methodology for scoping reviews was used, and systematic searches were carried out in six databases. A total of 59 articles published within the last 10 years were included based on certain eligibility criteria. The Research Pyramid was used to critically appraise these articles, suggesting that available research is of moderate quality. The descriptive content analysis of the articles revealed eight categories describing the characteristics of collaboration and coordination for people with dementia, as presented in previous articles. These characteristics are described in terms of different barriers, the function of the care coordinator, assessment and planning to provide services, interprofessional collaboration, information sharing, knowledge needed to navigate a complex health and care system and understanding of dementia, and personalisation of care. Engaging care coordinators with diverse competencies to address both medical and social care needs is essential, especially since people with dementia experience multiple and complex needs. It is also important to explain and visualise available services and when these services are suitable for implementation. Knowledge about dementia is necessary to empower people with dementia in everyday life situations.
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Health care providers face challenges in coordinating care across settings, particularly when dealing with complex medical needs alongside cognitive impairment.
“Health care providers similarly face challenges in coordinating care across settings, particularly when dealing with complex medical needs alongside cognitive impairment (Österholm et al., 2023).”
From Mind the gap: a systematic review of barriers, facilitators, and experiences of care transitions for people living with dementia and their informal caregivers. (2026) · cites this paper as Österholm et al., 2023
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- E. Risco, E. Cabrera, M. Farré, C. Alvira, S. Miguel, and A. Zabalegui, "Perspectives about health care crovision in cementia care in Spain: a qualitative study using focus-group methodology," American Journal of Alzheimer's Disease and Other Dementias, vol. 31, no. 3, pp. 223-230, 2016.
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Koh, W. Q., Roes, M., de Vugt, M. E., Sezgin, D., Gonçalves‐Pereira, M., Müller, N., Diaz-Ponce, A. M., Casey, D., Ingram, C., Walden, A., et al. (2025) · Aging & Mental Health · doi:10.1080/13607863.2025.2534406 · Cited by 16 · see citing works
Greene, L., Brain, J., Watkins, P., Kafadar, A. H., Sabatini, S., Blundell, B., Bothe, E., Harper, K., Hersh, D., Morrisby, C., et al. (2026) · The Gerontologist · doi:10.1093/geront/gnaf275 · Cited by 9 · see citing works
Dementia care management in primary care practices: a descriptive study among nurse practitioners
Poghosyan, L., Dougherty, M., Martsolf, G. R., Featherston, K. G., Porat‐Dahlerbruch, J., Soo Borson, B., Sadak, T. I., Wang, S. C., & O’Reilly-Jacob, M. (2025) · BMC Family Practice · doi:10.1186/s12875-025-02855-5 · Cited by 6 · see citing works
Working between systems: an umbrella review of care navigator roles and responsibilities
Wijekulasuriya, S., Wahlstrom, L., Lewis, S. P., Triandafilidis, Z., Rojas, C., Goodwin, N., Semkina, A., Boaz, A., Norrie, C., & Zurynski, Y. A. (2025) · Frontiers in Health Services · doi:10.3389/frhs.2025.1632307 · Cited by 3 · see citing works
Exploring Interprofessional Collaboration and Patient-Centered Care for People Living With Dementia
Campbell, J. L. (2025) · Home Healthcare Now · doi:10.1097/nhh.0000000000001366 · Cited by 2 · see citing works
Eid, H. R., Ørjasæter, K. B., & Bosnes, I. (2025) · Scandinavian Journal of Caring Sciences · doi:10.1111/scs.70108 · Cited by 1 · see citing works
CHUI, C. H.-K., Lu, S., Chan, O. F., Cheung, J. C.-S., Chiu, T. Y., & Lum, T. Y. S. (2025) · Research on Aging · doi:10.1177/01640275251370237
Andreassen, M., Törnqvist, T., & Österholm, J. (2026) · BMC Geriatrics · doi:10.1186/s12877-026-07637-x
Self-citationImpact of Serious Illnesses on Advance Care Planning Practice in Japan
Makihara, T., Hosoba, T., & Ochi, A. (2026) · Journal of Social Work in End-of-Life & Palliative Care · doi:10.1080/15524256.2026.2706478
Grundberg, Å., Sormunen, T., & Westerbotn, M. (2026) · Dementia · doi:10.1177/14713012261481860
Ugwu, U. C., & Ene, O. C. (2026) · Geriatric Nursing · doi:10.1016/j.gerinurse.2026.104347
- Authors
- Österholm, J., Larsson Ranada, Å., & Nedlund, A.-C.
- Affiliations
- Linköping University (SE)
- Linköping University, Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine, Unit of Occupational Therapy, Linköping, Sweden
- Corresponding author
- Österholm, Johannes
- Venue
- Health & Social Care in the Community
- Publisher
- Wiley
- Published
- 2023-11-27
- Volume
- 2023
- Pages
- 1-25
- ISSN
- 0966-0410 (ISSN-L)
- 1365-2524
- OpenAlex
- W4389058177
- Cited by
- 11
- References
- 92
- Citations by year
- 2026: 4 · 2025: 7
- FWCI
- 3.92
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Health & Social Care in the Community (publishedVersion, cc-by)
- KTH Publication Database DiVA (KTH Royal Institute of Technology) (submittedVersion, other-oa)
- Funders
- Forskningsrådet om Hälsa, Arbetsliv och Välfärd (STY-2021/0005 Dnr: 2021/01786)
- Topics
- Health Sciences › Health Professions › General Health Professions › Interprofessional Education and Collaboration
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Keywords
- dementia, older adults, health and care services, service coordination, interprofessional collaboration, care coordination, care coordinators, care fragmentation, information sharing, individualized care, dementia awareness, complex needs
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