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Introduction: Despite a generally decreased length of stay in Swedish hospitals, an increasing delay of discharge has been observed among patients with long‐term care need. Aim :Identify challenges and opportunities in the transition of patients between hospitals and out‐patient care. Method: Data were obtained from national registers on patients discharged from hospitals in 2014, interviews with public care authorities, and a systematic literature review. Results: A total of 1 121 823 persons were discharged from Swedish hospitals in 2014. Of all discharged patients, 334 420 (30%) was in need of further out‐patient medical care while 221 221 (20%) needed social services. Among these discharged patients, 53 763 (5%) needed both medical care and social services. In this group of frail persons (primarily females 80 years or older), 25 760 (48%) were readmitted to hospital within 30 days from the discharge. Main reported challenges in the transition were as follows: a decreasing number of beds in hospitals and nursing homes, lack of staff with proper education, and problems in transfer of information between caregivers. To solve these problems, respondents reported some new approaches: extensive initial home services after discharge, out‐patient care organised by both municipalities and county councils, local follow‐up of patient data as well as an emphasis on collaboration between caregivers. The literature reported ambiguous results about effects of single interventions at discharge. However, evidence suggests that the number of readmissions to hospital may be reduced by combining several interventions before discharge (individual planning, geriatric assessment, and patient education) with follow‐up after discharge. Conclusion: Since many frail patients are readmitted to hospital within 30 days after discharge, Swedish out‐patient care may need new working methods in order to promote a coherent care. Further, multi‐component interventions at discharge, including follow‐up after discharge, may prevent unintended readmissions. • Published by arrangement with John Wiley & Sons.

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