Table 1 Description of the themes and sub-themes that emerged from the data analyses

Facilitators and barriers

Intended communication ways

Primary communication

Description of the primary way of communication

Coordination meetings across organisations

Meetings related to general communication and collaboration (not related to specific patients). This was only found in Sweden

Insufficient information/communication regarding the patients care needs after discharge

When there is lacking information in the communication between the different actors or when information is sent out to late

Accessibility of collaborators

Possibility to reach other actors/collaborators when needed

Facilitators and barriers

Organisational structure

Guidelines and regulations

The guidelines and regulations provided

Extra resources for strengthening the coordination

Specific projects/extra resources put in place to facilitate better coordination

Uncertain responsibility

Uncertainty about who is responsible in specific situations

Staff influence on coordination and information

The staff’s possibility to influence the coordination and the information provided

Facilitators

Supplementary work

System knowledge

Knowledge about the system and the working conditions/responsibility of other actors

Additional communication initiated by staff (Not requested or part of general guidelines)

In cases where primary communication is not sufficient staff initiate communication by their own to get the information needed or to secure that important information is passed on

Work beyond duty

When the staff initiate responsibility on their own. Take responsibility in situation when it becomes unclear who is responsible or in situations where the system does not work. Efforts put in place by the personnel to balance system errors or to help smooth the coordination in addition to the official guidelines or communication ways