The integration of healthcare and social services has made collaborative care plans an important tool for health and social care professionals and the person involved. The collaborative planning process is challenging, and studies have revealed that its implementation and outcomes are not satisfactory for all participants. The study aimed to explore the collaborative planning process and attributes contributing to making the process work for all participants. The study focused on older adults in need of a collaborative care plan and adopted a grounded theory approach. Several sources were used to collect data from participants. The findings revealed an overarching process and two sub-processes. The overarching process “holding the links together” described the identified core attributes, joint philosophy, everyday practice and planning through partnership. The two sub-processes, “the missing link” and “connecting the links”, described the participants’ perspectives. The conceptual model explained the identified attributes and the connections between the overarching process and the two sub-processes. The study confirmed the complexity of collaboration between actors, professionals, older adults and informal caregivers. When one or more attribute did not function optimally or was missing, it affected the collaborative care planning process and participants involved, with consequences for the older adult. A joint philosophy, an ethic, could facilitate and guide professionals in everyday practice through all steps of the collaborative care planning process and contribute in making the process successful.