Table 1.

The prioritised themes expressed by frail older patients and relatives going through a care transition from the hospital to their own home or rehabilitation centre

Headlines (prioritised by importance)	Themes discussed by the expert panel					Not actively prioritised by the expert panel
Care contents: overview and responsibility	Health care personnel competency, options and drive: Granted services vs. the ability to deal with current individual needs	Identify and solve practical challenges	Number of carers/ health care professionals: too many/few/late/early/often or wrong profession
Relatives: involvement in care decisions	Involvement of the relatives during admission: consulting the relatives’ views	Involvement in care planning: participating relatives, assigning tasks to the relatives	Relatives taking an active part in the transition: being present at discharge	Relieve burdens off relatives and avoidance of overloading	Practically possible to be involved (time, place etc.)
Care transition: overview, responsibility	Manager/coordinator: to clarify and define responsibilities	Knowledge about options, e.g., whom to contact in case of unforeseen events				Match care and treatment plan expectations to reach common agreement
Existential issues	Existential and emotional considerations and reflections during admission, transition and after discharge
Functional capacity, illness and disease	Physical functional capacity and social capacity: regaining loss of function	To return home				Diagnostic conclusion: to understand what happened
Culture						Cultural understanding Language barrier