Prerequisites for people-centred collaboration explored through team-based oral health care planning in older adults’ home settings – a qualitative study

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An ageing population with multiple chronic diseases indicates the need for new ways of working, including teams consisting of different professionals. To enable this, a people-centred approach has been emphasized as important. This study therefore uses the World Health Organization Framework on integrated people-centred health services. The aim is to explore prerequisites for people-centred collaboration through team-based oral health care planning in older adults’ home settings. Methods: The design is qualitative, using qualitative content analysis with an inductive approach. A secondary analysis of data consisting of 24 team-based oral health care planning sessions conducted in older adults’ home settings was performed. Each team consisted of one older adult, one dental hygienist, and one home health care nurse. In total, 24 older adults, 7 dental hygienists, and 8 home health care nurses participated. Results: An overall theme identified was Practising a holistic approach during oral health care planning . A holistic care approach seemed to strengthen the prerequisites for a more integrated and people-centred care where the older adult’s general health and life situation was integrated in the overall oral health care planning. The results also emphasize the importance of creating a common platform or arena where older people, dental hygienists, and home health care nurses can contribute and share their knowledge and respective skills to learn from and guide one another. Conclusions: This study highlights that a holistic approach is essential for effective collaboration in team-based oral health care planning for older adults in home settings. Such an approach fosters an enabling environment, allowing care to be tailored to each individual’s specific needs by understanding what matters to each participant. By facilitating collaboration, the oral health care planning process can engage and empower participants, bridging critical aspects of care and enabling them to learn things they might not have discovered on their own. Care planning Collaboration Integrated care Nursing Oral health Person-centred care Introduction Globally, a demographic shift towards ageing populations is emerging, and along with it a growing need for more integrated care processes [1]. Older adults often face complex health challenges when suffering from several chronic diseases that require coordinated efforts from a diverse range of healthcare professionals. This multidisciplinary approach is essential to address the complex needs of the ageing population. There is a need for a shift from single-disease-focused care towards a comprehensive, person-centred approach that simultaneously addresses people’s medical, social, and psychological needs [2, 3]. One aspect that should be integrated further into complex, integrated care processes is oral health [4]. Oral health is crucial for overall quality of life. However, older adults with home care generally have poor oral health [5]. Poor oral health has been associated with malnutrition [6], diabetes [7], aspiration pneumonia [8], and cardiovascular diseases [9]. Moreover, it is well documented that older adults frequently lose contact with dental care services as they become more frail [10]. As oral diseases occur along with general diseases and share the same risk factors as other non-communicable diseases [11], this may indicate a need for integrating aspects of oral health into nursing care processes. However, oral health has been shown to be the most neglected area in care for older adults [12]. As implied, integrating oral health into the broader spectrum of care for older adults is not without its challenges. Barriers such as limited knowledge about oral health, varying attitudes towards aspects of oral health, unclear roles and responsibilities among healthcare providers, and fragmented financing systems all contribute to the difficulty of providing comprehensive care [13-16]. On an overall societal level, oral health and general health care are also facing numerous challenges regarding integration. These include a lack of political leadership, insufficient knowledge about the population’s oral health, low prioritization of oral health in political discussions, and ineffective oral health policies [17-19]. Niesten et al. [20] argue that the lack of a comprehensive macro-level vision and shared norms to guide the development of infrastructure, tools, and regulations for integrating oral health care makes it necessary to explore small-scale initiatives and local best practices to find the most effective approach. Integrated care processes indicate a need to explore the process of health care planning. Health care planning involves at least three key components: health, complex relationships between various participants involved in health care planning, and the balancing of different values, such as differing personal, clinical, and public health perspectives [21]. Leeftink et al. [22] conclude that there is a gap in research regarding multidisciplinary health care planning. Research regarding integrated team-based oral health care planning also seems to be very limited. For example, in a recent Swedish review of integrated person-centred interventions for older people’s care, none of the interventions involved dental care professionals or aspects of oral health [23]. The World Health Organization (WHO) Framework on Integrated People-Centred Health Services envisions a future where everyone has equitable access to high-quality health services that are collaboratively designed to meet people’s needs throughout their lives, respect their preferences, and are seamlessly coordinated across all levels of care [24]. These services should be comprehensive, safe, effective, timely, efficient, and acceptable, with all caregivers being motivated, skilled, and working in a supportive environment. It extends the concept of person-centred care to individual people, families, communities, and society. It could thus be considered to encompass the dental care domain as well. To achieve people-centred care, the WHO highlights five interdependent key areas: engaging and empowering people and communities, strengthening governance and accountability, reorienting the model of care, coordinating services across sectors, and creating an enabling environment. Nevertheless, little is known about how to facilitate collaboration, which could be regarded a prerequisite for these initiatives, also in home settings during team-based oral health planning. Therefore, the aim of this study is to explore prerequisites for people-centred collaboration through team-based oral health care planning in older adults’ home settings. Based on the aim and inspired by the framework for integrated people-centred health services, two research questions were formulated: What creates an enabling environment for collaboration in older adults’ home settings during collaborative oral health care planning? What engages and empowers people during collaborative oral health care planning in older adults’ home settings? Materials and Methods Design The study employs a qualitative design with an inductive approach. Data was gathered from 24 interprofessional, team-based oral assessments conducted in older adults’ ordinary home settings. Settings and participants Each team was composed of one older adult, one dental hygienist, and one home health care nurse. Data collection took place in the autumn of 2022 across seven municipalities in western Sweden, encompassing both rural and urban areas. Table 1 illustrates the population of each municipality and provides information on the participants. Table 1. Background data for municipalities and participants included in the study. Municipality A B C D E F G Population (n) 42 199 114 445 33 252 5 646 49 068 39 852 59 274 Team numbers 1–3 4–6 7–10 11–13 14–17 18–21 22–24 Nurses in home health care (n) 1 2* 1 1 1 1 1 Work experience (years) 10 17 18 20 8 15 2 Dental hygienists (n) 1 1 1 1 1 1 1 Work experience (years) 30 33 18 38 11 6 32 Older adults (n) 3 3 4 3 4 4 3 Age 91; 99; 87 87; 90; 92 91; 81; 91; 63 69; 76; 91 88; 86; 79; 87 91; 91; 71; 82 81; 81; 79 * One home health care nurse participated in two teams, and one participated only in one team. The participating professionals were included due to their extensive experience of working with older adults in clinical practice. The older adults were included if they had no cognitive decline, could understand Swedish, and were enrolled in home health care and in a dental care remuneration programme for frail older adults in Sweden [25]. The process of participant recruitment was as follows: initial contact regarding the study was made by JPK via email to seven managers in home health care and the manager of the public dental care remuneration programme. Information about the study was given to home health care nurses and dental hygienists during workplace meetings. Thereafter, the dental hygienists and home health care nurses who agreed to participate formed pairs and selected three to four older adults based on the criteria of inclusion. Consent was obtained from all parties for nurses and dental hygienists to participate if they chose to do so. All older adults were asked to participate by the home health nurse, and in total 28 older adults agreed to participate. However, four older adults withdrew their participation due to health issues. The participating older adults had been enrolled in home health care for 3 years (mean), with a range from 0 to 7 years. Four of the older adults were men and twenty were women. No particular training was given before the oral health care planning. The dental hygienists had never worked with the older adults or with the home health care nurses prior to the study. However, the home health care nurses were responsible for the older adults enrolled in the study in their everyday work life. Each oral health care planning lasted approximately 25 minutes. It was systematically conducted [26, 27] and included three phases: Self-reported health and oral health. This phase involved gathering self-reported data on general health and oral health from the older adults through questions such as ‘How do you feel?’ and ‘How do you feel in your mouth?’, along with follow-up questions. The objective was to capture the perspectives of the older adults and to support the establishment of a trustful treatment alliance [28]. Objective oral health assessment. We used the revised oral assessment guide [29], which is an oral health assessment tool designed for use by non-dental health professionals. It has demonstrated good validity and reliability [30]. The instrument includes nine items with response options ranging from 0 to 3, where 0 indicates ‘not applicable’, 1 ‘no problem’, 2 ‘oral health problem/risk’, and 3 ‘severe oral health problems/risk’. Preventive actions are planned based on the assessment. Moreover, for participants identified as having poor oral hygiene or gingivitis in the ‘teeth’ and ‘gums’ items, the underlying causes of their inability to manage daily oral care were further investigated using parts II and III of the Oral Hygiene Ability Instrument (OHAI) [31]. Part II involves a brief clinical examination to assess dry mouth, oral status, and muscular and spatial oral functions. Part III observes tooth brushing activities to identify impairments in fine motor skills or cognitive function affecting oral hygiene. Decision-making and action strategy. A shared protocol for oral assessment and documentation was used during health planning in home settings, facilitating planning and decision-making. The interactions within the teams were initiated through these phases and integrated into a shared paper-based prototype for a new ‘oral care card’ on a digital platform. This prototype was developed based on previous studies, with all phases performed collaboratively within the teams [13]. Data collection The data comprises transcriptions of 24 oral health care planning sessions. Most older adults were seated during the assessments (ROAG-J, OHAI Part II), although three participated while lying in bed. For those with poor oral hygiene, the toothbrushing activity in Part III of the OHAI was conducted as usual, typically in the bathroom by a washbasin. Instruments used during the oral assessments included a torch and a dental mirror. To ensure adherence to the study protocol, two researchers (JPK, AS) observed all the oral assessments without interfering. In four of the planning sessions, relatives participated at the request of the older adults (three daughters and one wife). The oral health care planning sessions were recorded with a Dictaphone and transcribed verbatim by JPK. Data analysis This study is part of an overall project on designing and evaluating a new model for team-based oral health care planning in older adults´ home settings in Sweden [32]. The data has been analysed, together with other data from the oral assessments, from a different perspective in a previous study [33] that aimed to investigate decisional needs during oral health assessments in ordinary home settings from the perspectives of older adults, home health care nurses, and dental hygienists. As such, this analysis can be considered a sub-analysis. We re-analysed the transcriptions of the interactions in the 24 oral assessments, allowing our research team to use an inductive approach, with a broad focus on prerequisites for people-centred collaboration. The data was analysed using qualitative content analysis [34, 35]. All transcriptions were independently read multiple times by SE and DL, who conducted an initial analysis which then was discussed together with JPK. Subsequently, the analysis was iteratively reviewed and discussed several times by all authors. Thereafter, EC conducted a validation of the analysis when approached with subthemes and was thereafter given meaning units to place in the different subthemes. All subthemes and meaning units were placed where they were supposed to by EC. The analysis was thereafter discussed within the whole research team, leading to a consensus. Table 2. Example of steps for data in the analysis. Quote Condensed unit of meaning Code Subtheme Theme Overarching theme Nurse 1 ‘Do you think it’s difficult to stand by the washbasin?’ Older adult 1 ‘A little, my feet won’t do what I want them to.’ Nurse 1 ‘There’s a good stool that you can get from rehab, so that you can sit down, too.’ Stool to sit on while brushing teeth Tools that help Adapting care to individual needs Learning from one another Holistic understanding Results An overall theme was identified as representing the overall prerequisite for people-centred oral health care planning in home settings where the older adult’s general health and life situation guide oral health planning, namely: Practising a holistic approach during oral health care planning . Table 3 the presents the overarching theme, themes and subthemes identified. Table 3. The overarching theme, themes and subthemes identified in the analysis. Overarching theme Practising a holistic approach during oral health care planning Themes Shared arenas and tools Learning from one other Subthemes Mapping the older adult’s status and needs Distributing roles and responsibilities Evaluating together Listening to understand Using a shared language Understanding ageing Tailoring care to individual needs Two main themes were identified as important prerequisites for collaborative oral health care planning. The first theme, ‘Shared arenas and tools’, highlights the importance of creating a common platform or arena where older adults, dental hygienists, and home care nurses all can contribute with their knowledge and skills. The second theme, ‘Learning from one other’, emphasizes the importance of mutual learning between the older adults and the two professions. Shared arenas and tools Having shared arenas and tools in everyday life seemed important for collaboration. It supported the participants in discussing and bridging knowledge, integrating each person’s life and context in oral health care Mapping the older adult’s status and needs The collaboration between the people in the teams, for example between the nurse in home care and the dental hygienist, was made possible by working side by side. In the oral health planning, the home care nurses contributed with their deep knowledge of the older adult’s history and daily condition, which contributed to a more comprehensive assessment of the patient’s status and needs. Home health care nurse, team 23: Now let’s assess the voice. Older adult, 76 years, team 23: Yes, it’s a little hoarse. Home health care nurse, team 23: And you usually are [hoarse]? And maybe it’s because your mouth is dry and at the same time you are a little asthmatic and such? Older adult, 76 years, team 23: Yes. And then, I became hoarse when I had the goitre operation. Dental hygienist, team 23: Yes, that is also a reason, of course. During several oral health assessments in the oral health care planning, the home health care nurses supported the dental hygienist – or vice versa – by, for example, holding an examination lamp. The team members guided each other by mapping the older adult’s status and needs together. The mapping of status and needs seemed to facilitate participation for all team members, strengthening the collaboration by enabling empowering aspects in care. Distributing roles and responsibilities In many of the team-based oral health assessments, it was discovered that the roles and responsibilities regarding daily oral care, use of oral hygiene products, or contact with dental care clinics had been unclearly distributed. Acknowledging oral health care aspects, and also being able to discuss and distribute roles and responsibilities, seemed to be important for people-centred collaboration. Home health care nurse, team 7: Do you manage to call dental care? Older adult, 91 years, team 7: No, I’m happy if you do it. Home health care nurse, team 7: Yes, I can help you call. The older adults were given the space to express their opinions to both caregivers, which created the conditions for joint decisions on the distribution of responsibilities based on the older person’s needs and wishes. In some teams, the older adults expressed a wish to be independent when it came to oral health issues. The teams could plan oral health care across organizations (dental and municipal health care) when distributing roles and responsibilities in a real-time dialogue. Evaluating together The home health care nurses and dental hygienists had never worked together before. Despite this, the pairs seemed to quickly adapt to working together and using each other as a sounding board when planning evaluations. This seemed to empower the participants while also ensuring the quality of care being planned. Home health care nurse, team 15: What do you think about following up on this? Because I could talk to her here in a couple of weeks and see whether it has had any effect. Dental hygienist, team 15: Yes. The joint oral health care planning seemed to open up for aspects of follow-up and evaluation of dental-care-related treatments and interventions that would not be possible for dental hygienists to perform themselves. For example, innovative suggestions emerged during the oral health care planning, such as offering dental care in home settings or using shared digital tools for joint evaluation. Learning from one another Taking part of each other’s knowledge and experiences was repeatedly stated as an important part of good collaboration in the oral health planning. Bridging knowledge and experiences by working in teams seemed to increase understanding between all parties. It appeared to lay a foundation for a holistic view of the older adult’s status and needs while enabling joint decisions about planning therapy and dividing responsibilities. Listening to understand Listening to each other was identified as a fundamental part of achieving increased understanding between all parties, facilitating collaboration. This was manifested in the form of follow-up questions, asking for examples, asking to show things, and letting each other finish speaking. This seemed to create an enabling environment for collaboration and also engaged the participants further in making the best possible oral health care plans for each individual older adult. Dental hygienist, team 13: What do you say if I say mouthwash with fluoride? Is that something you have talked about? Older adult, 79 years, team 13: Yes. We have at some point, but I can’t manage. Dental hygienist, team 13: Is it the taste, or is it the rinsing? Older adult, 79 years, team 13: No, it’s the rinsing, how to do it. In most of the oral health assessments, follow-up questions provided information that influenced how the teams decided to move forward in their oral health planning. Understanding between the parties provided a basis for good and individualized oral health planning with and for the older adult. Using a shared language The ability to make oneself understood seemed to be an essential part of good communication and cooperation. The use of a shared and understandable language proved to be crucial for effective communication between the caregivers and older adults. By adapting the language to the recipient and using familiar terms, a clearer dialogue was created that increased understanding between all participants in the oral health assessments. Dental hygienist, team 6: Do you still have all of your teeth? Older adult, 79 years, team 6: Yes, I don’t have any bought teeth dentures. Dental hygienist, team 6: You don’t have any bought teeth, no, and no prosthetics? Older adult, 79 years, team 6: No. Explaining terms, giving practical examples, showing things, and repeating oneself are all examples of tactics participants in the study used to ensure that recipients understood. A shared language seemed to contribute to increased understanding in the teams and to be a prerequisite for the participants to be able to learn from one another. Understanding ageing Working in teams in the older adults’ homes seemed to create a deeper understanding of ageing in regard to the individual older adult. Photos on the walls with people who no longer were alive, or seeing how everyday life at home could involve obstacles, seemed to offer a deeper view of what ageing was like for that particular individual, especially for the dental hygienists. For example, an older woman could not get into her bathroom with her wheelchair. Therefore, in that team it was suggested that daily oral care could be conducted in the kitchen. In most oral health planning, the older adults described problems stemming from, for example, impaired vision, impaired memory, impaired balance, systemic diseases, poorer hand coordination, and reduced motivation due to loneliness and moods. Older adult, 87 years, team 14: They pass away, you know. One by one. But that’s the course of life. You become lonely. Dental hygienist, team 14: How terrible. Deeper knowledge of the ageing process and its impact on older adults’ physical and mental health seemed to facilitate collaboration and increase understanding between all parties in the oral health assessments. This understanding of ageing within the teams seemed to facilitate collaboration and promote individualized decision-making in the oral health care planning for each older adult. Tailoring care to individual needs Team-based oral health planning sometimes seemed to promote the tailoring of care to each person’s unique needs and circumstances. This includes recognizing the physical limitations of some older adults and offering accessible and adaptable options. Home health care nurse, team 1: Do you think it’s difficult to stand by the washbasin? Older adult, 91 years, team 1: A little, my feet won’t do what I want them to. Home health care nurse, team 1: There’s a good stool that you can get from rehab, so that you can sit down, too. Knowledge of which resources such as tools and aids are available within each organization, both municipal health care and dental care, was positive for collaboration during oral health care planning to support each older adult. This facilitated suggesting possibilities that the other participants perhaps were not aware of. Discussion The aim of this study was to explore prerequisites for people-centred collaboration through team-based oral health care planning in older adults’ home settings. An overall theme was identified: Practising a holistic approach during oral health care planning . Employing a holistic approach appeared to create an enabling environment and to engage and empower the team members during team-based collaboration in home settings. The discussion will be guided by the framework for integrated people-centred health services by focusing on key aspects such as ‘an enabling environment’ and ‘engaging and empowering people’. Creating an enabling environment for team-based collaboration in home settings The results indicate that joint oral health care planning in home settings with older adults, home health care nurses, and dental hygienists is possible and can enable a common ground for collaboration to support the oral health of older adults in need of home care services. Considering the many barriers in terms of lack of political leadership, insufficient knowledge about the population’s oral health, low prioritization of oral health in political discussions, and ineffective oral health policies [17-20], it seems important to approach this issue not only from a micro perspective but also from a societal perspective. To address the issue of fragmented care and promote the oral and dental health of older adults, it seems crucial to create an enabling environment for team-based collaboration in home settings. This involves several key strategies aimed at fostering effective interprofessional collaboration and ensuring comprehensive care. From a societal point of view, how common arenas could be facilitated is yet to be explored and challenged. This is in line with McCormack [36], who suggests that strategies for person-centred care need to be approached on the micro-, meso- and macro level. Based on the results of this study, oral health care planning should consider the general health and living conditions of older adults. This holistic approach ensures that their oral health status and needs are accurately evaluated. The distribution of roles and responsibilities regarding older adults’ oral hygiene should be clear and developed in consultation with all professionals involved. This clarity ensures that each team member understands their specific duties and contributions. In a previous study within this project, professionals in dental and municipal care described difficulties with general written recommendations from dental care to home care settings [13]. It therefore seemed crucial to establish a common platform for interprofessional communication. For collaboration, a platform seems to facilitate seamless interaction between healthcare personnel involved in the older adults’ oral hygiene and health, ensuring that all relevant information is shared and considered. Considering the teams’ multiuser approach, using a shared language not specific to a profession during oral health care planning, supported by, for example, the validated instrument ROAG [29], seems to enhance understanding between dental hygienists, home care nurses, and older adults. This common language seemed to assist in tailoring care and bridging communication gaps, thereby fostering a more collaborative environment. Engaging and empowering people during team-based collaboration The results of this article emphasize that people involved in conducting team-based oral health care planning should strive to incorporate the knowledge and experiences of all parties involved. As visualized in the results, this can be achieved through follow-up questions and by allowing each party, including the older adult, to fully express their views. This inclusive approach ensures that all relevant insights are considered. This is in line with previous research stating that integrated person-centred care models should be able to comprehensively address the health of older adults, promoting improvements in their health and well-being while simultaneously preserving their autonomy and dignity [36]. When collaboration emerged in the oral health care planning process, it seemed to engage and empower the participants, making them ‘flourish’, as McCormack [37] describes it in a metaphor. For example, enhancing participants’ understanding of ageing or learning how to make an oral assessment as a home health care nurse seemed to make the participants more secure with one another. The overall oral health care planning thereby seemed to trigger further learning, where participants asked for mobile dental care units in home settings or digital tools for communication. By and large, professionals guiding each other seemed to engage and empower all participants in the teams, tailoring different aspects of care to each person´s specific needs. Methodological considerations A secondary analysis may sometimes not be appropriate, such as when the research question is unrelated or when there is a significant time gap between the primary and secondary analyses. However, it was well suited for the current study for several reasons. During the primary analysis [32], it became apparent that the deductive approach left much qualitative data unanalysed [34, 38]. Therefore, this secondary analysis serves as a complement, addressing important aspects of the primary phenomenon (i.e. collaborative oral health care planning in home settings) by focusing on collaboration. Additionally, this secondary analysis involved new researchers who were not part of the data collection or the primary design of the overall project, thereby facilitating validation of the entire project. Conclusions This study reveals that an overall prerequisite for facilitating collaboration during team-based oral health care planning in older adults’ home settings is to use a holistic approach. This seems to create an enabling environment, tailoring care to each individual’s specific needs based on learning what is important for each participant. When enabling collaboration, the process of oral health care planning can engage and empower participants, bridging important aspects of care and making participants learn things they could not have thought of themselves. Declarations The authors have nothing to declare. Human ethics and consent to participate The project is conducted in accordance with the guidelines of the Declaration of Helsinki and has received ethical approval from the Swedish Ethical Review Authority (no. 2022-03928-01). All participants provided their informed consent to participate, both orally and in writing. Consent for publication All authors consent to publication . Clinical trial number Not applicable. Availability of data and materials The datasets used and analysed in the current study are available from the corresponding author upon reasonable request. Competing interests Not applicable. Funding This research was funded by the Health Promotion Research Funding (VGFOUREG-937918, VGFOUREG-966932), Region Västra Götaland, Sweden and the Local Research and Development Board of Göteborg and Södra Bohuslän (VGFOUGSB-942302), Region Västra Götaland, Sweden. Authors’ contributions JPK conceptualized the project. 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L., Holmén, A., Strömberg, E., Gabre, P., & Wårdh, I. (2008). Who cares for the oral health of dependent elderly and disabled persons living at home? A qualitative study of case managers' knowledge, attitudes and initiatives. Swed Dent J , 32 (2), 95-104. Andersson, K., Furhoff, A. K., Nordenram, G., & Wardh, I. (2007). 'Oral health is not my department'. Perceptions of elderly patients' oral health by general medical practitioners in primary health care centres: a qualitative interview study. Scand J Caring Sci , 21 (1), 126-133. https://doi.org/10.1111/j.1471-6712.2007.00446.x Harnagea, H., Couturier, Y., Shrivastava, R., Girard, F., Lamothe, L., Bedos, C. P., & Emami, E. (2017). Barriers and facilitators in the integration of oral health into primary care: A scoping review. BMJ Open , 7 (9), e016078. https://doi.org/10.1136/bmjopen-2017-016078 Henni, S. H., Skudutyte-Rysstad, R., Ansteinsson, V., Hellesø, R., & Hovden, E. A. S. (2023). Oral health and oral health-related quality of life among older adults receiving home health care services: A scoping review. Gerodontology , 40 (2), 161–171. https://doi.org/10.1111/ger.12649 Olsen, C. F., Bergland, A., Debesay, J., Bye, A., & Langaas, A. G. (2019). Striking a balance: Health care providers’ experiences with home-based, patient-centered care for older people – A meta-synthesis of qualitative studies. Patient Education and Counselling , 102 (11), 1991–2000. https://doi.org/10.1016/j.pec.2019.05.017 Niesten, D., Gerritsen, A. E., & Leve, V. (2021). Barriers and facilitators to integrate oral health care for older adults in general (basic) care in East Netherlands. Part 2 Functional integration. Gerodontology , 38 (3), 289–299. https://doi.org/10.1111/ger.12525 Mirzoev, T. N., & Green, A. T. (2017). Planning, for Public Health Policy. In S. R. Quah (Ed.), International Encyclopedia of Public Health (Second Edition) (pp. 489-499). Academic Press. https://doi.org/https://doi.org/10.1016/B978-0-12-803678-5.00333-7 Leeftink, A. G., Bikker, I. A., Vliegen, I. M. H., & Boucherie, R. J. (2018). Multi-disciplinary planning in health care: a review. Health Syst (Basingstoke) , 9 (2), 95-118. https://doi.org/10.1080/20476965.2018.1436909 Kirvalidze, M., Boström, A. M., Liljas, A., Doheny, M., Hendry, A., McCormack, B., Fratiglioni, L., Ali, S., Ebrahimi, Z., Elmståhl, S., Eriksdotter, M., Gläske, P., Gustafsson, L. K., Rundgren Å, H., Hvitfeldt, H., Lennartsson, C., Hammar, L. M., Nilsson, G. H., Nilsson, P., . . . Calderón-Larrañaga, A. (2024). Effectiveness of integrated person-centered interventions for older people's care: Review of Swedish experiences and experts' perspective. J Intern Med , 295 (6), 804-824. https://doi.org/10.1111/joim.13784 World Health Organization. (2016). Framework on Integrated People-Centred Health Services. Available: EB Document Format SFS 1985:125. Swedish Dental Care Act. Westerlund, M., & Leminen, S. (2011). Managing the Challenges of Becoming an Open Innovation Company: Experiences from Living Labs. Technology Innovation Management Review , 1 , 19-25. Leminen, S., Westerlund, M., & Nyström, A.-G. Technology Innovation Management Review Living Labs as Open-innovation Networks. Stubbe, D. E. (2018). The Therapeutic Alliance: The Fundamental Element of Psychotherapy. Focus (Am Psychiatr Publ) , 16 (4), 402-403. https://doi.org/10.1176/appi.focus.20180022 Andersson, P., Hallberg, I. R., & Renvert, S. (2002). Inter-rater reliability of an oral assessment guide for elderly patients residing in a rehabilitation ward. Spec Care Dentist , 22 (5), 181-186. https://doi.org/10.1111/j.1754-4505.2002.tb00268.x Everaars, B., Weening-Verbree, L. F., Jerković-Ćosić, K., Schoonmade, L., Bleijenberg, N., de Wit, N. J., & van der Heijden, G. J. M. G. (2020). Measurement properties of oral health assessments for non-dental healthcare professionals in older people: a systematic review. BMC Geriatrics , 20 (1), 4–4. https://doi.org/10.1186/s12877-019-1349-y Grönbeck Lindén, I., Andersson, P., Dahlin Ivanoff, S., Gahnberg, L., & Hägglin, C. (2024). Evaluation of the Oral Hygiene Ability Instrument (OHAI): Test of reliability. Int J Dent Hyg , 22 (3), 769-778. https://doi.org/10.1111/idh.12792 Persson Kylén, J., Björns, S., Hägglin, C. et al. Evaluation of collaborative oral health care planning between older adults and personnel from public dental care and municipal care organizations: a study protocol for a cluster-randomized controlled study in Sweden. Trials 26 , 57 (2025). https://doi.org/10.1186/s13063-025-08753-6 Persson Kylén, J., Björns, S., Hägglin, C., Grönbeck-Lindén, I., Piper, L., & Wårdh, I. (2024). Decisional needs for older adults, home health care nurses and dental hygienists during team-based oral health assessments in ordinary home settings - a qualitative study. BMC Geriatr , 24 (1), 779. https://doi.org/10.1186/s12877-024-05367-6 Graneheim, U. H., Lindgren, B. M., & Lundman, B. (2017). Methodological challenges in qualitative content analysis: A discussion paper. Nurse Educ Today , 56 , 29-34. https://doi.org/10.1016/j.nedt.2017.06.002 Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today , 24 (2), 105-112. https://doi.org/10.1016/j.nedt.2003.10.001 McCormack, B., & McCance, T. (Eds.) (2016). Person-centred Practice in Nursing and Healthcare . John Wiley & Sons, Inc. McCormack, B. (2024). The ecology of human flourishing embodying the changes we want to see in the world. Nursing Philosophy , 25 (3), e12482. https://doi.org/https://doi.org/10.1111/nup.12482 Lindgren, B. M., Lundman, B., & Graneheim, U. H. (2020). Abstraction and interpretation during the qualitative content analysis process. Int J Nurs Stud , 108 , 103632. https://doi.org/10.1016/j.ijnurstu.2020.103632 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 12 Jun, 2025 Reviewers invited by journal 04 Jun, 2025 Editor invited by journal 07 May, 2025 Editor assigned by journal 02 May, 2025 Submission checks completed at journal 02 May, 2025 First submitted to journal 21 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6494979","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":456407656,"identity":"34e29ded-aebb-4c76-8d25-a4ea5530cee6","order_by":0,"name":"Jessica Persson Kylén","email":"data:image/png;base64,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","orcid":"","institution":"University West","correspondingAuthor":true,"prefix":"","firstName":"Jessica","middleName":"Persson","lastName":"Kylén","suffix":""},{"id":456407657,"identity":"f349258b-ec03-4b94-aa0c-f6dfb6f0c02e","order_by":1,"name":"Siri Elmér","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Siri","middleName":"","lastName":"Elmér","suffix":""},{"id":456407658,"identity":"2c198ca4-8239-4d32-ae00-8b155a84dce4","order_by":2,"name":"Diana Laylani","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Diana","middleName":"","lastName":"Laylani","suffix":""},{"id":456407659,"identity":"cb31f28f-b99f-4660-a66a-fb6dc516d8bd","order_by":3,"name":"Emina Cirgic","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Emina","middleName":"","lastName":"Cirgic","suffix":""}],"badges":[],"createdAt":"2025-04-21 10:08:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6494979/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6494979/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83747007,"identity":"aa39d8b4-8a07-452e-ac09-2811ed22d771","added_by":"auto","created_at":"2025-06-02 05:07:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":835165,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6494979/v1/34962060-3d11-44a6-aa83-1c6143b09a05.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prerequisites for people-centred collaboration explored through team-based oral health care planning in older adults’ home settings – a qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGlobally, a demographic shift towards ageing populations is emerging, and along with it a growing need for more integrated care processes [1]. Older adults often face complex health challenges when suffering from several chronic diseases that require coordinated efforts from a diverse range of healthcare professionals. This multidisciplinary approach is essential to address the complex needs of the ageing population. There is a need for a shift from single-disease-focused care towards a comprehensive, person-centred approach that simultaneously addresses people’s medical, social, and psychological needs [2, 3].\u003c/p\u003e\n\u003cp\u003eOne aspect that should be integrated further into complex, integrated care processes is oral health [4]. Oral health is crucial for overall quality of life. However, older adults with home care generally have poor oral health [5]. Poor oral health has been associated with malnutrition [6], diabetes [7], aspiration pneumonia [8], and cardiovascular diseases [9]. Moreover, it is well documented that older adults frequently lose contact with dental care services as they become more frail [10]. As oral diseases occur along with general diseases and share the same risk factors as other non-communicable diseases [11], this may indicate a need for integrating aspects of oral health into nursing care processes. However, oral health has been shown to be the most neglected area in care for older adults [12].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs implied, integrating oral health into the broader spectrum of care for older adults is not without its challenges. Barriers such as limited knowledge about oral health, varying attitudes towards aspects of oral health, unclear roles and responsibilities among healthcare providers, and fragmented financing systems all contribute to the difficulty of providing comprehensive care [13-16]. On an overall societal level, oral health and general health care are also facing numerous challenges regarding integration. These include a lack of political leadership, insufficient knowledge about the population’s oral health, low prioritization of oral health in political discussions, and ineffective oral health policies [17-19]. Niesten et al. [20] argue that the lack of a comprehensive macro-level vision and shared norms to guide the development of infrastructure, tools, and regulations for integrating oral health care makes it necessary to explore small-scale initiatives and local best practices to find the most effective approach.\u003c/p\u003e\n\u003cp\u003eIntegrated care processes indicate a need to explore the process of health care planning. Health care planning involves at least three key components: health, complex relationships between various participants involved in health care planning, and the balancing of different values, such as differing personal, clinical, and public health perspectives [21]. Leeftink et al. [22] conclude that there is a gap in research regarding multidisciplinary health care planning. Research regarding integrated team-based oral health care planning also seems to be very limited. For example, in a recent Swedish review of integrated person-centred interventions for older people’s care, none of the interventions involved dental care professionals or aspects of oral health [23].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe World Health Organization (WHO) Framework on Integrated People-Centred Health Services envisions a future where everyone has equitable access to high-quality health services that are collaboratively designed to meet people’s needs throughout their lives, respect their preferences, and are seamlessly coordinated across all levels of care [24]. These services should be comprehensive, safe, effective, timely, efficient, and acceptable, with all caregivers being motivated, skilled, and working in a supportive environment. It extends the concept of person-centred care to individual people, families, communities, and society. It could thus be considered to encompass the dental care domain as well. To achieve people-centred care, the WHO highlights five interdependent key areas: engaging and empowering people and communities, strengthening governance and accountability, reorienting the model of care, coordinating services across sectors, and creating an enabling environment. Nevertheless, little is known about how to facilitate collaboration, which could be regarded a prerequisite for these initiatives, also in home settings during team-based oral health planning. Therefore, the aim of this study is to explore prerequisites for people-centred collaboration through team-based oral health care planning in older adults’ home settings. Based on the aim and inspired by the framework for integrated people-centred health services, two research questions were formulated:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eWhat creates an enabling environment for collaboration in older adults’ home settings during collaborative oral health care planning?\u003c/li\u003e\n \u003cli\u003eWhat engages and empowers people during collaborative oral health care planning in older adults’ home settings?\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Materials and Methods","content":"\u003ch2\u003eDesign\u003c/h2\u003e\n\u003cp\u003eThe study employs a qualitative design with an inductive approach. Data was gathered from 24 interprofessional, team-based oral assessments conducted in older adults\u0026rsquo; ordinary home settings.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eSettings and participants\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eEach team was composed of one older adult, one dental hygienist, and one home health care nurse. Data collection took place in the autumn of 2022 across seven municipalities in western Sweden, encompassing both rural and urban areas. Table 1 illustrates the population of each municipality and provides information on the participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eBackground data for municipalities and participants included in the study.\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"582\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMunicipality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003ePopulation (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e42 199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e114 445\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e33 252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e5 646\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e49 068\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e39 852\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e59 274\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eTeam numbers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u0026ndash;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4\u0026ndash;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e7\u0026ndash;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e11\u0026ndash;13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e14\u0026ndash;17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e18\u0026ndash;21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e22\u0026ndash;24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eNurses in home health care (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eWork experience (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eDental hygienists (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eWork experience (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOlder adults (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e91; 99; 87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e87; 90;\u0026nbsp;\u003cbr\u003e\u0026nbsp;92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e91; 81; 91; 63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e69; 76; 91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e88; 86; 79; 87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e91; 91; 71; 82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e81; 81; 79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e* One home health care nurse participated in two teams, and one participated only in one team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe participating professionals were included due to their extensive experience of working with older adults in clinical practice. The older adults were included if they had no cognitive decline, could understand Swedish, and were enrolled in home health care and in a dental care remuneration programme for frail older adults in Sweden [25].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe process of participant recruitment was as follows: initial contact regarding the study was made by JPK via email to seven managers in home health care and the manager of the public dental care remuneration programme. Information about the study was given to home health care nurses and dental hygienists during workplace meetings. Thereafter, the dental hygienists and home health care nurses who agreed to participate formed pairs and selected three to four older adults based on the criteria of inclusion. Consent was obtained from all parties for nurses and dental hygienists to participate if they chose to do so. All older adults were asked to participate by the home health nurse, and in total 28 older adults agreed to participate. However, four older adults withdrew their participation due to health issues. The participating older adults had been enrolled in home health care for 3 years (mean), with a range from 0 to 7 years. Four of the older adults were men and twenty were women.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo particular training was given before the oral health care planning. The dental hygienists had never worked with the older adults or with the home health care nurses prior to the study. However, the home health care nurses were responsible for the older adults enrolled in the study in their everyday work life. Each oral health care planning lasted approximately 25 minutes. It was systematically conducted [26, 27] and included three phases:\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eSelf-reported health and oral health. This phase involved gathering self-reported data on general health and oral health from the older adults through questions such as \u0026lsquo;How do you feel?\u0026rsquo; and \u0026lsquo;How do you feel in your mouth?\u0026rsquo;, along with follow-up questions. The objective was to capture the perspectives of the older adults and to support the establishment of a trustful treatment alliance [28].\u003c/li\u003e\n \u003cli\u003eObjective oral health assessment. We used the revised oral assessment guide [29], which is an oral health assessment tool designed for use by non-dental health professionals. It has demonstrated good validity and reliability [30]. The instrument includes nine items with response options ranging from 0 to 3, where 0 indicates \u0026lsquo;not applicable\u0026rsquo;, 1 \u0026lsquo;no problem\u0026rsquo;, 2 \u0026lsquo;oral health problem/risk\u0026rsquo;, and 3 \u0026lsquo;severe oral health problems/risk\u0026rsquo;. Preventive actions are planned based on the assessment. Moreover, for participants identified as having poor oral hygiene or gingivitis in the \u0026lsquo;teeth\u0026rsquo; and \u0026lsquo;gums\u0026rsquo; items, the underlying causes of their inability to manage daily oral care were further investigated using parts II and III of the Oral Hygiene Ability Instrument (OHAI) [31]. Part II involves a brief clinical examination to assess dry mouth, oral status, and muscular and spatial oral functions. Part III observes tooth brushing activities to identify impairments in fine motor skills or cognitive function affecting oral hygiene.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDecision-making and action strategy. A\u0026nbsp;shared protocol for oral assessment and documentation was used during health planning in home settings, facilitating planning and decision-making. The interactions within the teams were initiated through these phases and integrated into a shared paper-based prototype for a new \u0026lsquo;oral care card\u0026rsquo; on a digital platform. This prototype was developed based on previous studies, with all phases performed collaboratively within the teams [13].\u003c/li\u003e\n\u003c/ol\u003e\n\u003ch2\u003eData collection\u003c/h2\u003e\n\u003cp\u003eThe data comprises transcriptions of 24 oral health care planning sessions. Most older adults were seated during the assessments (ROAG-J, OHAI Part II), although three participated while lying in bed. For those with poor oral hygiene, the toothbrushing activity in Part III of the OHAI was conducted as usual, typically in the bathroom by a washbasin. Instruments used during the oral assessments included a torch and a dental mirror. To ensure adherence to the study protocol, two researchers (JPK, AS) observed all the oral assessments without interfering. In four of the planning sessions, relatives participated at the request of the older adults (three daughters and one wife). The oral health care planning sessions were recorded with a Dictaphone and transcribed verbatim by JPK.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eThis study is part of an overall project on designing and evaluating a new model for team-based oral health care planning in older adults\u0026acute; home settings in Sweden [32]. The data has been analysed, together with other data from the oral assessments, \u0026nbsp;from a different perspective in a previous study [33] that aimed to investigate decisional needs during oral health assessments in ordinary home settings from the perspectives of older adults, home health care nurses, and dental hygienists. As such, this analysis can be considered a sub-analysis. We re-analysed the transcriptions of the interactions in the 24 oral assessments, allowing our research team to use an inductive approach, with a broad focus on prerequisites for people-centred collaboration. The data was analysed using qualitative content analysis [34, 35]. All transcriptions were independently read multiple times by SE and DL, who conducted an initial analysis which then was discussed together with JPK. Subsequently, the analysis was iteratively reviewed and discussed several times by all authors. Thereafter, EC conducted a validation of the analysis when approached with subthemes and was thereafter given meaning units to place in the different subthemes. All subthemes and meaning units were placed where they were supposed to by EC. The analysis was thereafter discussed within the whole research team, leading to a consensus.\u003c/p\u003e\n\u003cp\u003eTable 2. Example of steps for data in the analysis.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuote\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCondensed unit of meaning\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCode\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubtheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverarching theme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNurse 1\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;Do you think it\u0026rsquo;s difficult to stand by the washbasin?\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eOlder adult 1\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003cem\u003e\u0026lsquo;A little, my feet won\u0026rsquo;t do what I want them to.\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eNurse 1\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;There\u0026rsquo;s a good stool that you can get from rehab, so that you can sit down, too.\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStool to sit on while brushing teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTools that help\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAdapting care to individual needs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLearning from one another\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHolistic understanding\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Results","content":"\u003cp\u003eAn overall theme was identified as representing the overall prerequisite for people-centred oral health care planning in home settings where the older adult\u0026rsquo;s general health and life situation guide oral health planning, namely: \u003cem\u003ePractising a holistic approach during oral health care planning\u003c/em\u003e. Table 3 the presents the overarching theme, themes and subthemes identified.\u003c/p\u003e\n\u003cp\u003eTable 3. The overarching theme, themes and subthemes identified in the analysis.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOverarching theme\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePractising a holistic approach during oral health care planning\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThemes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShared arenas and tools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLearning from one other\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSubthemes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMapping the older adult\u0026rsquo;s status and needs\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDistributing roles and responsibilities\u003c/p\u003e\n \u003cp\u003eEvaluating together\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eListening to understand\u003c/p\u003e\n \u003cp\u003eUsing a shared language\u003c/p\u003e\n \u003cp\u003eUnderstanding ageing\u003c/p\u003e\n \u003cp\u003eTailoring care to individual needs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTwo main themes were identified as important prerequisites for collaborative oral health care planning. The first theme, \u0026lsquo;Shared arenas and tools\u0026rsquo;, highlights the importance of creating a common platform or arena where older adults, dental hygienists, and home care nurses all can contribute with their knowledge and skills. The second theme, \u0026lsquo;Learning from one other\u0026rsquo;, emphasizes the importance of mutual learning between the older adults and the two professions.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eShared arenas and tools\u003c/h2\u003e\n\u003cp\u003eHaving shared arenas and tools in everyday life seemed important for collaboration. It supported the participants in discussing and bridging knowledge, integrating each person\u0026rsquo;s life and context in oral health care\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eMapping the older adult\u0026rsquo;s status and needs\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe collaboration between the people in the teams, for example between the nurse in home care and the dental hygienist, was made possible by working side by side. In the oral health planning, the home care nurses contributed with their deep knowledge of the older adult\u0026rsquo;s history and daily condition, which contributed to a more comprehensive assessment of the patient\u0026rsquo;s status and needs.\u003c/p\u003e\n\u003cp\u003eHome health care nurse, team 23: \u003cem\u003eNow let\u0026rsquo;s assess the voice.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOlder adult, 76 years, team 23:\u003cem\u003e\u0026nbsp;Yes, it\u0026rsquo;s a little hoarse.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHome health care nurse, team 23:\u003cem\u003e\u0026nbsp;And you usually are [hoarse]? And maybe it\u0026rsquo;s because your mouth is dry and at the same time you are a little asthmatic and such?\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOlder adult, 76 years, team 23: \u003cem\u003eYes. And then, I became hoarse when I had the goitre operation.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDental hygienist, team 23:\u003cem\u003e\u0026nbsp;Yes, that is also a reason, of course.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDuring several oral health assessments in the oral health care planning, the home health care nurses supported the dental hygienist \u0026ndash; or vice versa \u0026ndash; by, for example, holding an examination lamp. The team members guided each other by mapping the older adult\u0026rsquo;s status and needs together. The mapping of status and needs seemed to facilitate participation for all team members, strengthening the collaboration by enabling empowering aspects in care.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eDistributing roles and responsibilities\u003c/h3\u003e\n\u003cp\u003eIn many of the team-based oral health assessments, it was discovered that the roles and responsibilities regarding daily oral care, use of oral hygiene products, or contact with dental care clinics had been unclearly distributed. Acknowledging oral health care aspects, and also being able to discuss and distribute roles and responsibilities, seemed to be important for people-centred collaboration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHome health care nurse, team 7:\u003cem\u003e\u0026nbsp;Do you manage to call dental care?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOlder adult, 91 years, team 7: \u003cem\u003eNo, I\u0026rsquo;m happy if you do it.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHome health care nurse, team 7:\u003cem\u003e\u0026nbsp;Yes, I can help you call.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe older adults were given the space to express their opinions to both caregivers, which created the conditions for joint decisions on the distribution of responsibilities based on the older person\u0026rsquo;s needs and wishes. In some teams, the older adults expressed a wish to be independent when it came to oral health issues. The teams could plan oral health care across organizations (dental and municipal health care) when distributing roles and responsibilities in a real-time dialogue.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eEvaluating together\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe home health care nurses and dental hygienists had never worked together before. Despite this, the pairs seemed to quickly adapt to working together and using each other as a sounding board when planning evaluations. This seemed to empower the participants while also ensuring the quality of care being planned.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHome health care nurse, team 15:\u003cem\u003e\u0026nbsp;What do you think about following up on this? Because I could talk to her here in a couple of weeks and see whether it has had any effect.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDental hygienist, team 15:\u003cem\u003e\u0026nbsp;Yes.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe joint oral health care planning seemed to open up for aspects of follow-up and evaluation of dental-care-related treatments and interventions that would not be possible for dental hygienists to perform themselves. For example, innovative suggestions emerged during the oral health care planning, such as offering dental care in home settings or using shared digital tools for joint evaluation.\u003c/p\u003e\n\u003ch2\u003eLearning from one another\u003c/h2\u003e\n\u003cp\u003eTaking part of each other\u0026rsquo;s knowledge and experiences was repeatedly stated as an important part of good collaboration in the oral health planning. Bridging knowledge and experiences by working in teams seemed to increase understanding between all parties. It appeared to lay a foundation for a holistic view of the older adult\u0026rsquo;s status and needs while enabling joint decisions about planning therapy and dividing responsibilities.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eListening to understand\u003c/h3\u003e\n\u003cp\u003eListening to each other was identified as a fundamental part of achieving increased understanding between all parties, facilitating collaboration. This was manifested in the form of follow-up questions, asking for examples, asking to show things, and letting each other finish speaking. This seemed to create an enabling environment for collaboration and also engaged the participants further in making the best possible oral health care plans for each individual older adult.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDental hygienist, team 13: \u003cem\u003eWhat do you say if I say mouthwash with fluoride? Is that something you have talked about?\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOlder adult, 79 years, team 13: \u003cem\u003eYes. We have at some point, but I can\u0026rsquo;t manage.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDental hygienist, team 13: \u003cem\u003eIs it the taste, or is it the rinsing?\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOlder adult, 79 years, team 13: \u003cem\u003eNo, it\u0026rsquo;s the rinsing, how to do it.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn most of the oral health assessments, follow-up questions provided information that influenced how the teams decided to move forward in their oral health planning. Understanding between the parties provided a basis for good and individualized oral health planning with and for the older adult.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eUsing a shared language\u003c/h3\u003e\n\u003cp\u003eThe ability to make oneself understood seemed to be an essential part of good communication and cooperation. The use of a shared and understandable language proved to be crucial for effective communication between the caregivers and older adults. By adapting the language to the recipient and using familiar terms, a clearer dialogue was created that increased understanding between all participants in the oral health assessments.\u003c/p\u003e\n\u003cp\u003eDental hygienist, team 6: \u003cem\u003eDo you still have all of your teeth?\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOlder adult, 79 years, team 6:\u003cem\u003e\u0026nbsp;Yes, I don\u0026rsquo;t have any bought teeth dentures.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDental hygienist, team 6:\u003cem\u003e\u0026nbsp;You don\u0026rsquo;t have any bought teeth, no, and no prosthetics?\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOlder adult, 79 years, team 6:\u003cem\u003e\u0026nbsp;No.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eExplaining terms, giving practical examples, showing things, and repeating oneself are all examples of tactics participants in the study used to ensure that recipients understood. A shared language seemed to contribute to increased understanding in the teams and to be a prerequisite for the participants to be able to learn from one another.\u003c/p\u003e\n\u003ch3\u003eUnderstanding ageing\u003c/h3\u003e\n\u003cp\u003eWorking in teams in the older adults\u0026rsquo; homes seemed to create a deeper understanding of ageing in regard to the individual older adult. Photos on the walls with people who no longer were alive, or seeing how everyday life at home could involve obstacles, seemed to offer a deeper view of what ageing was like for that particular individual, especially for the dental hygienists. For example, an older woman could not get into her bathroom with her wheelchair. Therefore, in that team it was suggested that daily oral care could be conducted in the kitchen. In most oral health planning, the older adults described problems stemming from, for example, impaired vision, impaired memory, impaired balance, systemic diseases, poorer hand coordination, and reduced motivation due to loneliness and moods.\u003c/p\u003e\n\u003cp\u003eOlder adult, 87 years, team 14: \u003cem\u003eThey pass away, you know. One by one. But that\u0026rsquo;s the course of life. You become lonely.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDental hygienist, team 14:\u003cem\u003e\u0026nbsp;How terrible.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDeeper knowledge of the ageing process and its impact on older adults\u0026rsquo; physical and mental health seemed to facilitate collaboration and increase understanding between all parties in the oral health assessments. This understanding of ageing within the teams seemed to facilitate collaboration and promote individualized decision-making in the oral health care planning for each older adult.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eTailoring care to individual needs\u003c/h3\u003e\n\u003cp\u003eTeam-based oral health planning sometimes seemed to promote the tailoring of care to each person\u0026rsquo;s unique needs and circumstances. This includes recognizing the physical limitations of some older adults and offering accessible and adaptable options.\u003c/p\u003e\n\u003cp\u003eHome health care nurse, team 1:\u003cem\u003e\u0026nbsp;Do you think it\u0026rsquo;s difficult to stand by the washbasin?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOlder adult, 91 years, team 1:\u003cem\u003e\u0026nbsp;A little, my feet won\u0026rsquo;t do what I want them to.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHome health care nurse, team 1:\u003cem\u003e\u0026nbsp;There\u0026rsquo;s a good stool that you can get from rehab, so that you can sit down, too.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eKnowledge of which resources such as tools and aids are available within each organization, both municipal health care and dental care, was positive for collaboration during oral health care planning to support each older adult. This facilitated suggesting possibilities that the other participants perhaps were not aware of.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of this study was to explore prerequisites for people-centred collaboration through team-based oral health care planning in older adults\u0026rsquo; home settings. An overall theme was identified: \u003cem\u003ePractising a holistic approach during oral health care planning\u003c/em\u003e. Employing a holistic approach appeared to create an enabling environment and to engage and empower the team members during team-based collaboration in home settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe discussion will be guided by the framework for integrated people-centred health services by focusing on key aspects such as \u0026lsquo;an enabling environment\u0026rsquo; and \u0026lsquo;engaging and empowering people\u0026rsquo;.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCreating an enabling environment for team-based collaboration in home settings\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe results indicate that joint oral health care planning in home settings with older adults, home health care nurses, and dental hygienists is possible and can enable a common ground for collaboration to support the oral health of older adults in need of home care services. Considering the many barriers in terms of lack of political leadership, insufficient knowledge about the population\u0026rsquo;s oral health, low prioritization of oral health in political discussions, and ineffective oral health policies [17-20], it seems important to approach this issue not only from a micro perspective but also from a societal perspective.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo address the issue of fragmented care and promote the oral and dental health of older adults, it seems crucial to create an enabling environment for team-based collaboration in home settings. This involves several key strategies aimed at fostering effective interprofessional collaboration and ensuring comprehensive care. From a societal point of view, how common arenas could be facilitated is yet to be explored and challenged. This is in line with McCormack [36], who suggests that strategies for person-centred care need to be approached on the micro-, meso- and macro level. Based on the results of this study, oral health care planning should consider the general health and living conditions of older adults. This holistic approach ensures that their oral health status and needs are accurately evaluated.\u0026nbsp;The distribution of roles and responsibilities regarding older adults\u0026rsquo; oral hygiene should be clear and developed in consultation with all professionals involved. This clarity ensures that each team member understands their specific duties and contributions.\u003c/p\u003e\n\u003cp\u003eIn a previous study within this project, professionals in dental and municipal care described difficulties with general written recommendations from dental care to home care settings [13]. It therefore seemed crucial to establish a common platform for interprofessional communication. For collaboration, a platform seems to facilitate seamless interaction between healthcare personnel involved in the older adults\u0026rsquo; oral hygiene and health, ensuring that all relevant information is shared and considered. Considering the teams\u0026rsquo; multiuser approach, using a shared language not specific to a profession during oral health care planning, supported by, for example, the validated instrument ROAG [29], seems to enhance understanding between dental hygienists, home care nurses, and older adults. This common language seemed to assist in tailoring care and bridging communication gaps, thereby fostering a more collaborative environment.\u003c/p\u003e\n\u003ch2\u003eEngaging and empowering people during team-based collaboration\u003c/h2\u003e\n\u003cp\u003eThe results of this article emphasize that people involved in conducting team-based oral health care planning should strive to incorporate the knowledge and experiences of all parties involved. As visualized in the results, this can be achieved through follow-up questions and by allowing each party, including the older adult, to fully express their views. This inclusive approach ensures that all relevant insights are considered. This is in line with previous research stating that integrated person-centred care models should be able to comprehensively address the health of older adults, promoting improvements in their health and well-being while simultaneously preserving their autonomy and dignity [36]. When collaboration emerged in the oral health care planning process, it seemed to engage and empower the participants, making them \u0026lsquo;flourish\u0026rsquo;, as McCormack [37] describes it in a metaphor. For example, enhancing participants\u0026rsquo; understanding of ageing or learning how to make an oral assessment as a home health care nurse seemed to make the participants more secure with one another. The overall oral health care planning thereby seemed to trigger further learning, where participants asked for mobile dental care units in home settings or digital tools for communication. By and large, professionals guiding each other seemed to engage and empower all participants in the teams, tailoring different aspects of care to each person\u0026acute;s specific needs.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eMethodological considerations\u003c/h2\u003e\n\u003cp\u003eA secondary analysis may sometimes not be appropriate, such as when the research question is unrelated or when there is a significant time gap between the primary and secondary analyses. However, it was well suited for the current study for several reasons. During the primary analysis [32], it became apparent that the deductive approach left much qualitative data unanalysed [34, 38]. Therefore, this secondary analysis serves as a complement, addressing important aspects of the primary phenomenon (i.e. collaborative oral health care planning in home settings) by focusing on collaboration. Additionally, this secondary analysis involved new researchers who were not part of the data collection or the primary design of the overall project, thereby facilitating validation of the entire project.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study reveals that an overall prerequisite for facilitating collaboration during team-based oral health care planning in older adults’ home settings is to use a holistic approach. This seems to create an enabling environment, tailoring care to each individual’s specific needs based on learning what is important for each participant. When enabling collaboration, the process of oral health care planning can engage and empower participants, bridging important aspects of care and making participants learn things they could not have thought of themselves.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors have nothing to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman ethics and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project is conducted in accordance with the guidelines of the Declaration of Helsinki and has received ethical approval from the Swedish Ethical Review Authority (no. 2022-03928-01). All participants provided their informed consent to participate, both orally and in writing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors consent to publication\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed in the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the Health Promotion Research Funding (VGFOUREG-937918, VGFOUREG-966932), Region Västra Götaland, Sweden and the Local Research and Development Board of Göteborg and Södra Bohuslän (VGFOUGSB-942302), Region Västra Götaland, Sweden.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJPK conceptualized the project. The manuscript was discussed, read, and revised by all authors (JPK, SE, DL, EC), who also approved its publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors extend their gratitude to Professor Ann Svensson (AS) for observing all oral assessments. They also sincerely thank all participants involved in the data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Health Organization. (2021). \u003cem\u003eDecade of healthy ageing: Baseline report\u003c/em\u003e. ISBN:\u0026nbsp;9789240017900\u003c/li\u003e\n \u003cli\u003eOlde Rikkert, M. G. M., Melis, R. J. F., Cohen, A. A., \u0026amp; Peeters, G. M. E. E. (2022). Why illness is more important than disease in old age. \u003cem\u003eAge and Ageing\u003c/em\u003e,\u003cem\u003e\u0026nbsp;51\u003c/em\u003e(1). https://doi.org/10.1093/ageing/afab267\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTinetti, M. 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Part 2 Functional integration. \u003cem\u003eGerodontology\u003c/em\u003e,\u003cem\u003e\u0026nbsp;38\u003c/em\u003e(3), 289\u0026ndash;299. https://doi.org/10.1111/ger.12525\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMirzoev, T. N., \u0026amp; Green, A. T. (2017). Planning, for Public Health Policy. In S. R. Quah (Ed.), \u003cem\u003eInternational Encyclopedia of Public Health (Second Edition)\u003c/em\u003e (pp. 489-499). Academic Press. https://doi.org/https://doi.org/10.1016/B978-0-12-803678-5.00333-7\u003c/li\u003e\n \u003cli\u003eLeeftink, A. G., Bikker, I. A., Vliegen, I. M. H., \u0026amp; Boucherie, R. J. (2018). Multi-disciplinary planning in health care: a review. \u003cem\u003eHealth Syst (Basingstoke)\u003c/em\u003e,\u003cem\u003e\u0026nbsp;9\u003c/em\u003e(2), 95-118. https://doi.org/10.1080/20476965.2018.1436909\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKirvalidze, M., Bostr\u0026ouml;m, A. M., Liljas, A., Doheny, M., Hendry, A., McCormack, B., Fratiglioni, L., Ali, S., Ebrahimi, Z., Elmst\u0026aring;hl, S., Eriksdotter, M., Gl\u0026auml;ske, P., Gustafsson, L. K., Rundgren \u0026Aring;, H., Hvitfeldt, H., Lennartsson, C., Hammar, L. M., Nilsson, G. H., Nilsson, P., . . . Calder\u0026oacute;n-Larra\u0026ntilde;aga, A. (2024). Effectiveness of integrated person-centered interventions for older people\u0026apos;s care: Review of Swedish experiences and experts\u0026apos; perspective.\u0026nbsp;\u003cem\u003eJ Intern Med\u003c/em\u003e,\u003cem\u003e\u0026nbsp;295\u003c/em\u003e(6), 804-824. https://doi.org/10.1111/joim.13784\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2016). \u003cem\u003eFramework on Integrated People-Centred Health Services.\u0026nbsp;\u003c/em\u003eAvailable:\u003cem\u003eEB Document Format\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003eSFS 1985:125. 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Inter-rater reliability of an oral assessment guide for elderly patients residing in a rehabilitation ward.\u0026nbsp;\u003cem\u003eSpec Care Dentist\u003c/em\u003e,\u003cem\u003e\u0026nbsp;22\u003c/em\u003e(5), 181-186. https://doi.org/10.1111/j.1754-4505.2002.tb00268.x\u003c/li\u003e\n \u003cli\u003eEveraars, B., Weening-Verbree, L. F., Jerković-Ćosić, K., Schoonmade, L., Bleijenberg, N., de Wit, N. J., \u0026amp; van der Heijden, G. J. M. G. (2020). Measurement properties of oral health assessments for non-dental healthcare professionals in older people: a systematic review. \u003cem\u003eBMC Geriatrics\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(1), 4\u0026ndash;4. https://doi.org/10.1186/s12877-019-1349-y\u003c/li\u003e\n \u003cli\u003eGr\u0026ouml;nbeck Lind\u0026eacute;n, I., Andersson, P., Dahlin Ivanoff, S., Gahnberg, L., \u0026amp; H\u0026auml;gglin, C. (2024). Evaluation of the Oral Hygiene Ability Instrument (OHAI): Test of reliability.\u0026nbsp;\u003cem\u003eInt J Dent Hyg\u003c/em\u003e,\u003cem\u003e\u0026nbsp;22\u003c/em\u003e(3), 769-778. https://doi.org/10.1111/idh.12792\u003c/li\u003e\n \u003cli\u003ePersson Kyl\u0026eacute;n, J., Bj\u0026ouml;rns, S., H\u0026auml;gglin, C. \u003cem\u003eet al.\u003c/em\u003e Evaluation of collaborative oral health care planning between older adults and personnel from public dental care and municipal care organizations: a study protocol for a cluster-randomized controlled study in Sweden. \u003cem\u003eTrials\u003c/em\u003e \u003cstrong\u003e26\u003c/strong\u003e, 57 (2025). https://doi.org/10.1186/s13063-025-08753-6\u003c/li\u003e\n \u003cli\u003ePersson Kyl\u0026eacute;n, J., Bj\u0026ouml;rns, S., H\u0026auml;gglin, C., Gr\u0026ouml;nbeck-Lind\u0026eacute;n, I., Piper, L., \u0026amp; W\u0026aring;rdh, I. (2024). Decisional needs for older adults, home health care nurses and dental hygienists during team-based oral health assessments in ordinary home settings - a qualitative study. \u003cem\u003eBMC Geriatr\u003c/em\u003e,\u003cem\u003e\u0026nbsp;24\u003c/em\u003e(1), 779. https://doi.org/10.1186/s12877-024-05367-6\u003c/li\u003e\n \u003cli\u003eGraneheim, U. H., Lindgren, B. M., \u0026amp; Lundman, B. (2017). Methodological challenges in qualitative content analysis: A discussion paper. \u003cem\u003eNurse Educ Today\u003c/em\u003e,\u003cem\u003e\u0026nbsp;56\u003c/em\u003e, 29-34. https://doi.org/10.1016/j.nedt.2017.06.002\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGraneheim, U. H., \u0026amp; Lundman, B. (2004). Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. \u003cem\u003eNurse Educ Today\u003c/em\u003e,\u003cem\u003e\u0026nbsp;24\u003c/em\u003e(2), 105-112. https://doi.org/10.1016/j.nedt.2003.10.001\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMcCormack, B., \u0026amp; McCance, T. (Eds.) (2016). \u003cem\u003ePerson-centred Practice in Nursing and Healthcare\u003c/em\u003e. John Wiley \u0026amp; Sons, Inc.\u003c/li\u003e\n \u003cli\u003eMcCormack, B. (2024). The ecology of human flourishing embodying the changes we want to see in the world. \u003cem\u003eNursing Philosophy\u003c/em\u003e,\u003cem\u003e\u0026nbsp;25\u003c/em\u003e(3), e12482. https://doi.org/https://doi.org/10.1111/nup.12482\u003c/li\u003e\n \u003cli\u003eLindgren, B. M., Lundman, B., \u0026amp; Graneheim, U. H. (2020). Abstraction and interpretation during the qualitative content analysis process. \u003cem\u003eInt J Nurs Stud\u003c/em\u003e,\u003cem\u003e\u0026nbsp;108\u003c/em\u003e, 103632. https://doi.org/10.1016/j.ijnurstu.2020.103632\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Care planning, Collaboration, Integrated care, Nursing, Oral health, Person-centred care","lastPublishedDoi":"10.21203/rs.3.rs-6494979/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6494979/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe dental and healthcare sector faces future challenges concerning financing, organization, skills, and competence. An ageing population with multiple chronic diseases indicates the need for new ways of working, including teams consisting of different professionals. To enable this, a people-centred approach has been emphasized as important. This study therefore uses the World Health Organization Framework on integrated people-centred health services. The aim is to explore prerequisites for people-centred collaboration through team-based oral health care planning in older adults’ home settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The design is qualitative, using qualitative content analysis with an inductive approach. A secondary analysis of data consisting of 24 team-based oral health care planning sessions conducted in older adults’ home settings was performed. Each team consisted of one older adult, one dental hygienist, and one home health care nurse. In total, 24 older adults, 7 dental hygienists, and 8 home health care nurses participated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e An overall theme identified was \u003cem\u003ePractising a holistic approach during oral health care planning\u003c/em\u003e. A holistic care approach seemed to strengthen the prerequisites for a more integrated and people-centred care where the older adult’s general health and life situation was integrated in the overall oral health care planning. The results also emphasize the importance of creating a common platform or arena where older people, dental hygienists, and home health care nurses can contribute and share their knowledge and respective skills to learn from and guide one another.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This study highlights that a holistic approach is essential for effective collaboration in team-based oral health care planning for older adults in home settings. Such an approach fosters an enabling environment, allowing care to be tailored to each individual’s specific needs by understanding what matters to each participant. By facilitating collaboration, the oral health care planning process can engage and empower participants, bridging critical aspects of care and enabling them to learn things they might not have discovered on their own.\u003c/p\u003e","manuscriptTitle":"Prerequisites for people-centred collaboration explored through team-based oral health care planning in older adults’ home settings – a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-02 04:59:20","doi":"10.21203/rs.3.rs-6494979/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"181123372823402335508853889602906247128","date":"2025-06-12T11:18:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-05T03:28:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-07T17:45:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-02T09:32:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-02T09:27:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-04-21T10:02:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b22b725e-df61-4c7e-9e1e-b615ff9af11e","owner":[],"postedDate":"June 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-05T03:38:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-02 04:59:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6494979","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6494979","identity":"rs-6494979","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}