Unseen and unread decision letters in everyday care: a case study of medication management assistance in Norwegian municipal home healthcare

Abstract Background Medication safety in home healthcare is critical for older adults with multimorbidity and polypharmacy. Norwegian municipalities allocate medication management support through legally binding individual decision letters intended to ensure transparency and guide care. Their practical role in everyday medication management remains unclear. This study explores how individual decision letters facilitate safe medication management practice in municipal home healthcare services. Methods A qualitative multiple-case study was conducted across three rural municipalities. Data comprised 15 decision letters and 35 semi-structured interviews with nine patients, one general practitioner, four nurses, and two service allocators over 12 months. Reflexive thematic analysis was used to identify patterns in how the decision letters were interpreted and implemented in practice. Results Decision letters were seldom read by patients or nurses and often used vague language that required interpretation. Nurses relied on supplementary structures – care plans, task lists, and verbal agreements – to operationalise medication support. Variability in interpretation and revision processes created uncertainty for patients and limited their ability to exercise their rights. Financial constraints further shaped service allocation. Conclusion Decision letters function primarily as formal legal instruments rather than practical guides. Their limited clarity and accessibility reinforce reliance on informal systems and discretionary practices. Enhancing language precision, integrating letters with care plans, and involving patients in reassessments may improve medication safety and patient empowerment.