This review includes 121 publications from research and development projects concerning patient pathways for elderly people with chronical illnesses in the community health care and between different levels in the health care services.

The Norwegian health care service is described as a complex and fragmented system which is constantly dealing with a severe pressure. This is a challenge for holistic care pathways for elderly patients with chronical illnesses, since these pathways often contain several critical transitions. Clinical guidelines developed for single diseases, in addition to fragmented and poor coordinated services, is pointed out as challenging for patients with several multichronical illnesses – also known as multimorbidity.

Furthermore, there is a focus on poor information flow during transitions between hospital and community, and on distinct differences in approaches and perspectives between specialist- and primary health care services. The specialist health care service mainly focuses on the patient’s needs in a short time perspective. In addition, it is having a medically, diagnosis oriented approach. On the other hand, the primary health care service mainly focuses on the patient’s needs in a long-term perspective, emphasizing their level of function, coping ability, quality of life, and home situation. Different perspectives related to patient’s need of care is further reflected in different understandings of the term “ready to be discharged”. Several publications point at the fact that the coordination reform has resulted in a larger number of patients with more medical needs in the communities, and to a higher rate of readmissions in hospital. In addition, these publications show that hospitals discharge patients too soon, and many patients are not treated to a complete healing before discharged. Furthermore, it is reported in several publications that the community does not have sufficient knowledge to receive these patients from hospital. Challenges related to poor economic resources in the communities are also pointed out as important in these matters.

Standardized care pathways and the use of check-lists are described as good tools in improving transitions from hospitals to communities and to strengthen the monitoring of patients, while the use of IT and care messages (PLO-messages) are described as tools that can contribute to better flow of information. Different models of cooperation between hospital and community are measures considered to improve transition of knowledge and increase understanding of the patient’s situation. Further, this can result in better transitions and continuity in patient pathways. The implementation of intermediate units and municipal emergency bed units (KAD) are described as important and successful initiatives to improve transitions between hospital and community. However, challenges in organization of the services are also discussed. Elderly people discharged from hospital to the community, will according to literature benefit from interconnected and targeted initiatives to improve transitions between different levels in the health care system.