User Experience and Care Integration in Transitional Care for Older People From Hospital to Home: A Meta-Synthesis

Patient medication management, understanding and adherence during the transition from hospital to outpatient care - a qualitative longitudinal study in polymorbid patients with type 2 diabetes

BACKGROUND

Continuity of care is under great pressure during the transition from hospital to outpatient care. Medication changes during hospitalization may be poorly communicated and understood, compromising patient safety during the transition from hospital to home. The main aims of this study were to investigate the perspectives of patients with type 2 diabetes and multimorbidities on their medications from hospital discharge to outpatient care, and their healthcare journey through the outpatient healthcare system. In this article, we present the results focusing on patients' perspectives of their medications from hospital to two months after discharge.

METHODS

Patients with type 2 diabetes, with at least two comorbidities and who returned home after discharge, were recruited during their hospitalization. A descriptive qualitative longitudinal research approach was adopted, with four in-depth semi-structured interviews per participant over a period of two months after discharge. Interviews were based on semi-structured guides, transcribed verbatim, and a thematic analysis was conducted.

RESULTS

Twenty-one participants were included from October 2020 to July 2021. Seventy-five interviews were conducted. Three main themes were identified: (A) Medication management, (B) Medication understanding, and (C) Medication adherence, during three periods: (1) Hospitalization, (2) Care transition, and (3) Outpatient care. Participants had varying levels of need for medication information and involvement in medication management during hospitalization and in outpatient care. The transition from hospital to autonomous medication management was difficult for most participants, who quickly returned to their routines with some participants experiencing difficulties in medication adherence.

CONCLUSIONS

The transition from hospital to outpatient care is a challenging process during which discharged patients are vulnerable and are willing to take steps to better manage, understand, and adhere to their medications. The resulting tension between patients' difficulties with their medications and lack of standardized healthcare support calls for interprofessional guidelines to better address patients' needs, increase their safety, and standardize physicians', pharmacists', and nurses' roles and responsibilities.

"Being the main character but not always involved in one's own care transition" - a qualitative descriptive study of older adults' experiences of being discharged from in-patient care to home

BACKGROUND

The growing number of older adults with chronic diseases challenges already strained healthcare systems. Fragmented systems make transitions between healthcare settings demanding, posing risks during transitions from in-patient care to home. Despite efforts to make healthcare person-centered during care transitions, previous research indicates that these ambitions are not yet achieved. Therefore, there is a need to examine whether recent initiatives have positively influenced older adults' experiences of transitions from in-patient care to home. This study aimed to describe older adults' experiences of being discharged from in-patient care to home.

METHODS

This study had a qualitative descriptive design. Individual interviews were conducted in January-June 2022 with 17 older Swedish adults with chronic diseases and needing coordinated care transitions from in-patient care to home. Data were analyzed using inductive qualitative content analysis.

RESULTS

The findings indicate that despite being the supposed main character, the older adult is not always involved in the planning and decision-making of their own care transition, often having poor insight and involvement in, and impact on, these aspects. This leads to an experience of mismatch between actual needs and the expectations of planned support after discharge.

CONCLUSIONS

The study reveals a notable disparity between the assumed central role of older adults in care transitions and their insight and involvement in planning and decision-making.

Navigating outpatient care of patients with type 2 diabetes after hospital discharge - a qualitative longitudinal study

BACKGROUND

The transition from hospital to outpatient care is a particularly vulnerable period for patients as they move from regular health monitoring to self-management. This study aimed to map and investigate the journey of patients with polymorbidities, including type 2 diabetes (T2D), in the 2 months following hospital discharge and examine patients' encounters with healthcare professionals (HCPs).

METHODS

Patients discharged with T2D and at least two other comorbidities were recruited during hospitalization. This qualitative longitudinal study consisted of four semi-structured interviews per participant conducted from discharge up to 2 months after discharge. The interviews were based on a guide, transcribed verbatim, and thematically analyzed. Patient journeys through the healthcare system were represented using the patient journey mapping methodology.

RESULTS

Seventy-five interviews with 21 participants were conducted from October 2020 to July 2021. The participants had a median of 11 encounters (min-max: 6-28) with HCPs. The patient journey was categorized into six key steps: hospitalization, discharge, dispensing prescribed medications by the community pharmacist, follow-up calls, the first medical appointment, and outpatient care.

CONCLUSIONS

The outpatient journey in the 2 months following discharge is a complex and adaptive process. Despite the active role of numerous HCPs, navigation in outpatient care after discharge relies heavily on the involvement and responsibilities of patients. Preparation for discharge, post-hospitalization follow-up, and the first visit to the pharmacy and general practitioner are key moments for carefully considering patient care. Our findings underline the need for clarified roles and a standardized approach to discharge planning and post-discharge care in partnership with patients, family caregivers, and all stakeholders involved.

In the footstep of the old patient from hospital to home: A qualitative field observation study

BACKGROUND

Older people often have multiple health conditions and therefore extended care needs. The transition from the hospital back to their home requires careful planning. The fragmented healthcare system and rapid discharge from the hospital can result in limited involvement of the older patient in the discharge planning process. We aimed to explore how older hospitalised patients experienced the transition from hospital to home and how possibilities and constraints in interactions with relevant parties in the transition affected their everyday lives.

METHOD

An ethnographic participant observation study including interviews was conducted with 10 older hospitalised patients. The theoretical perspective in the study is critical psychology and data were analysed using the condition-, meaning- and reasoning analysis.

RESULTS

Three themes were identified: (1) Lost in transition - the person's ability to act is limited, (2) In transition - the relatives become important, (3) At home - the home transforms into a workplace.

CONCLUSION

Lack of involvement becomes a condition for older patients as some struggle to create meaning in their transition, affecting their everyday lives. The patients experienced their relatives as important as they ensured that the HCPs got to know their values and wishes. This knowledge is important for HCPs working closely with older people both at the hospital and at home ensuring active involvement of the older person with respect and acknowledgement of the older person's wishes, needs, resources and vulnerability.

Head Protection Device for Individuals at Risk for Head Injury due to Ground-Level Falls: Single Trauma Center User Experience Investigation

BACKGROUND

Falls represent a large percentage of hospitalized patients with trauma as they may result in head injuries. Brain injury from ground-level falls (GLFs) in patients is common and has substantial mortality. As fall prevention initiatives have been inconclusive, we changed our strategy to injury prevention. We identified a head protection device (HPD) with impact-resistant technology, which meets head impact criteria sustained in a GLF. HPDs such as helmets are ubiquitous in preventing head injuries in sports and industrial activities; yet, they have not been studied for daily activities.

OBJECTIVE

We investigated the usability of a novel HPD on patients with head injury in acute care and home contexts to predict future compliance.

METHODS

A total of 26 individuals who sustained head injuries, wore an HPD in the hospital, while ambulatory and were evaluated at baseline and 2 months post discharge. Clinical and demographic data were collected; a usability survey captured HPD domains. This user experience design revealed patient perceptions, satisfaction, and compliance. Nonparametric tests were used for intragroup comparisons (Wilcoxon signed rank test). Differences between categorical variables including sex, race, and age (age group 1: 55-77 years; age group 2: 78+ years) and compliance were tested using the chi-square test.

RESULTS

Of the 26 patients enrolled, 12 (46%) were female, 18 (69%) were on anticoagulants, and 25 (96%) were admitted with a head injury due to a GLF. The median age was 77 (IQR 55-92) years. After 2 months, 22 (85%) wore the device with 0 falls and no GLF hospital readmissions. Usability assessment with 26 patients revealed positive scores for the HPD post discharge regarding satisfaction (mean 4.8, SD 0.89), usability (mean 4.23, SD 0.86), effectiveness (mean 4.69, SD 0.54), and relevance (mean 4.12, SD 1.10). Nonparametric tests showed positive results with no significant differences between 2 observations. One issue emerged in the domain of aesthetics; post discharge, 8 (30%) patients had a concern about device weight. Analysis showed differences in patient compliance regarding age (χ12=4.27; P=.04) but not sex (χ12=1.58; P=.23) or race (χ12=0.75; P=.60). Age group 1 was more likely to wear the device for normal daily activities. Patients most often wore the device ambulating, and protection was identified as the primary benefit.

CONCLUSIONS

The HPD intervention is likely to have reasonably high compliance in a population at risk for GLFs as it was considered usable, protective, and relevant. The feasibility and wearability of the device in patients who are at risk for GLFs will inform future directions, which includes a multicenter study to evaluate device compliance and effectiveness. Our work will guide other institutions in pursuing technologies and interventions that are effective in mitigating injury in the event of a fall in this high-risk population.

Healthcare providers' perceived acceptability of a warning signs intervention for rural hospital-to-home transitional care: A cross-sectional study

INTRODUCTION

There is a pressing need for transitional care that prepares rural dwelling medical patients to identify and respond to the signs of worsening health conditions. An evidence-based warning signs intervention has the potential to address this need. While the intervention is predominantly delivered by nurses, other healthcare providers may be required to deliver it in rural communities where human health resources are typically limited. Understanding the perspectives of other healthcare providers likely to be involved in delivering the intervention is a necessary first step to avert consequences of low acceptability, such as poor intervention implementation, uptake, and effectiveness. This study examined and compared nurses' and other healthcare providers' perceived acceptability of an evidence-based warning signs intervention proposed for rural transitional care.

METHODS

A cross-sectional design was used. The convenience sample included 45 nurses and 32 other healthcare providers (e.g., physical and occupational therapists, physicians) who self-identified as delivering transitional care to patients in rural Ontario, Canada. In an online survey, participants were presented with a description of the warning signs intervention and completed established measures of intervention acceptability. The measures captured 10 intervention acceptability attributes (effectiveness, appropriateness, risk, convenience, relevance, applicability, usefulness, frequency of current use, likelihood of future use, and confidence in ability to deliver the intervention). Ratings ≥ 2 indicated acceptability. Data analysis included descriptive statistics, independent samples t-tests, as well as effect sizes to quantify the magnitude of any differences in acceptability ratings between nurses and other healthcare providers.

RESULTS

Nurses and other healthcare providers rated all intervention attributes > 2, except the attributes of convenience and frequency of current use. Differences between the two groups were found for only three attributes: nurses' ratings were significantly higher than other healthcare providers on perceived applicability, frequency of current use, and the likelihood of future use of the intervention (all p's < .007; effect sizes .58 - .68, respectively).

DISCUSSION

The results indicate that both participant groups had positive perspectives of the intervention on most of the attributes and suggest that initiatives to enhance the convenience of the intervention's implementation are warranted to support its widespread adoption in rural transitional care. However, the results also suggest that other healthcare providers may be less receptive to the intervention in practice. Future research is needed to explore and mitigate the possible reasons for low ratings on perceived convenience and frequency of current use of the intervention, as well as the between group differences on perceived applicability, frequency of current use, and the likelihood of future use of the intervention.

CONCLUSIONS

The intervention represents a tenable option for rural transitional care in Ontario, Canada, and possibly other jurisdictions emphasizing transitional care.

Bed flow priorities and the spatial and temporal dimensions of rural older adult care

Despite prior research that examines the spatial and temporal dimensions of older adult care, there is disparate research on the influence of patient flow priorities on older adult care over time and place. Drawing on a qualitative case study of rural older adult transitions in care in the Canadian context we examine how patient flow prioritization undervalues older patients' needs and the local contexts in which care is provided. Certainly, accounting for the spatial and temporal dimensions of older adult care has broader implications that will enhance future research, policy and practice. Policy makers, researchers and clinicians may then use these recommendations as a stepping stone to align the health care system with the older populations that they serve.

Understanding data collection strategies for the ethical inclusion of older adults with disabilities in transitional care research: A scoping review protocol

INTRODUCTION

A growing body of evidence suggests that older adults are particularly vulnerable to poor care as they transition across care environments. Thus, they require transitional care services as they transition across healthcare settings. To help make intervention research meaningful to the older adults the intervention aims to serve, many researchers aim to study their experiences, by actively involving them in research processes. However, collecting data from older adults with various forms of disability often assumes that the research methods selected are appropriate for them. This scoping review will map the evidence on research methods to collect data from older adults with disabilities within the transitional care literature.

METHODS

The proposed scoping review follows the framework originally described by the Joanna Briggs Institute (JBI) Manual: (1) developing a search strategy, (2) evidence screening and selection, (3) data extraction; and (4) analysis. We will include studies identified through a comprehensive search of peer-reviewed and empirical literature reporting on research methods used to elicit the experiences of older adults with disabilities in transitional care interventions. In addition, we will search the reference lists of included studies. The findings of this review will be narratively synthesized. The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews will guide the reporting of the methods and results.

DISCUSSION

The overarching goal of this study is to develop strategies to assist the research community in increasing the inclusion of older adults with disabilities in transitional care research. The findings of this review will highlight recommendations for research to inform data collection within future intervention research for older adults with disabilities. Study findings will be disseminated via a publication and presentations.

Safeguarding survival: Older persons with multiple chronic conditions' unplanned readmission experiences: A mixed methods systematic review

AIMS AND OBJECTIVES

The aim of this study was to create a holistic understanding of the psychosocial processes of older persons with multiple chronic conditions' experience with unplanned readmission experiences within 30 days of discharge home and identify factors influencing these psychosocial processes.

DESIGN

Mixed methods systematic review.

DATA SOURCES

Six electronic databases (Ovid MEDLINE (R) All 1946-present, Scopus, CINAHL, Embase, PsychINFO and Web of Science).

REVIEW METHODS

Peer-reviewed articles published between 2010 and 2021 and addressed study aims (n = 6116) were screened. Studies were categorised by method: qualitative and quantitative. Qualitative data synthesis used a meta-synthesis approach and applied thematic analysis. Quantitative data synthesis used vote counting. Data (qualitative and quantitative) were integrated through aggregation and configuration.

RESULTS

Ten articles (n = 5 qualitative; n = 5 quantitative) were included. 'Safeguarding survival' described older persons' unplanned readmission experience. Older persons experienced three psychosocial processes: identifying missing pieces of care, reaching for lifelines and feeling unsafe. Factors influencing these psychosocial processes included chronic conditions and discharge diagnosis, increased assistance with functional needs, lack of discharge planning, lack of support, increased intensity of symptoms and previous hospital readmission experiences.

CONCLUSIONS

Older persons felt more unsafe as their symptoms increased in intensity and unmanageability. Unplanned readmission was an action older persons required to safeguard their recovery and survival.

RELEVANCE TO CLINICAL PRACTICE

Nurses play a critical role in assessing and addressing factors that influence older persons' unplanned readmission. Identifying older persons' knowledge about chronic conditions, discharge planning, support (caregivers and community services), changes in functional needs, intensity of symptoms and past readmission experiences may prepare older persons to cope with their return home. Focusing on their health-care needs across the continuum of care (community, home and hospital) will mitigate the risks for unplanned readmission within 30 days of discharge.

REPORTING METHOD

PRISMA guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution due to design.

Evaluating step-down, intermediate care programme in Buckinghamshire, UK: a mixed methods study

BACKGROUND

Intermediate care (IC) services are models of care that aim to bridge the gap between hospital and home, enabling continuity of care and the transition to the community. The purpose of this study was to explore patient experience with a step-down, intermediate care unit in Buckinghamshire, UK.

METHODS

A mixed-methods study design was used. Twenty-eight responses to a patient feedback questionnaire were analysed and seven qualitative semi-structured interviews were conducted. The eligible participants were patients who had been admitted to the step-down IC unit. Interview transcripts were analysed using thematic analysis.

FINDINGS

Our interview data generated five core themes: (1) "Being uninformed", (2) "Caring relationships with health practitioners", (3) "Experiencing good intermediate care", (4) "Rehabilitation" and (5) "Discussing the care plan". When comparing the quantitative to the qualitative data, these themes are consistent.

CONCLUSIONS

Overall, the patients reported that the admission to the step-down care facility was positive. Patients highlighted the supportive relationship they formed with healthcare professionals in the IC and that the rehabilitation that was offered in the IC service was important in increasing mobility and regaining their independence. In addition, patients reported that they were largely unaware about their transfer to the IC unit before this occurred and they were also unaware of their discharge package of care. These findings will inform the evolving patient-centred journey for service development within intermediate care.

Lost in transition? Community residential facility staff and stakeholder perspectives on previously incarcerated older adults' transitions into long-term care

BACKGROUND

Establishing an effective continuum of care is a pivotal part of providing support for older populations. In contemporary practice; however, a subset of older adults experience delayed entry and/or are denied access to appropriate care. While previously incarcerated older adults often face barriers to accessing health care services to support community reintegration, there has been limited research on their transitions into long-term care. Exploring these transitions, we aim to highlight the challenges of securing long-term care services for previously incarcerated older adults and shed light on the contextual landscape that reinforces the inequitable care of marginalized older populations across the care continuum.

METHODS

We performed a case study of a Community Residential Facility (CRF) for previously incarcerated older adults which leverages best practices in transitional care interventions. Semi-structured interviews were conducted with CRF staff and community stakeholders to determine the challenges and barriers of this population when reintegrating back into the community. A secondary thematic analysis was conducted to specifically examine the challenges of accessing long-term care. A code manual representing the project themes (e.g., access to care, long-term care, inequitable experiences) was tested and revised, following an iterative collaborative qualitative analysis (ICQA) process.

RESULTS

The findings indicate that previously incarcerated older adults experience delayed access and/or are denied entry into long-term care due to stigma and a culture of risk that overshadow the admissions process. These circumstances combined with few available long-term care options and the prominence of complex populations already in long-term care contribute to the inequitable access barriers of previously incarcerated older adults seeking entry into long-term care.

CONCLUSIONS

We emphasize the many strengths of utilizing transitional care interventions to support previously incarcerated older adults as they transition into long-term care including: 1) education & training, 2) advocacy, and 3) a shared responsibility of care. On the other hand, we underscore that more work is needed to redress the layered bureaucracy of long-term care admissions processes, the lack of long-term care options and the barriers imposed by restrictive long-term care eligibility criteria that sustain the inequitable care of marginalized older populations.

Evaluating a transitional care program for the oldest adults: results from the quantitative phase of a mixed-methods study

Purpose

This quantitative phase of a mixed-methods study aims to describe the effect of the Transitional Care Bridge (TCB) programme on functional decline, mortality, health-care utilisation and health outcomes compared to usual care in a regional hospital in the Netherlands.

Design/methodology/approach

In a pre- and post-cohort study, patients aged ≥70 years, admitted to the hospital for ≥48 h and discharged home with an Identification of Seniors at Risk score of ≥2, were included. The TCB programme, started before discharge, encompassed six visits by the community nurse (CN). Data were obtained from the hospital registry and by three questionnaires over a three months period, addressing activities of daily living (ADL), self-rated health, self-rated quality of life and health-care utilisation.

Findings

In total, 100 patients were enrolled in this study, 50 patients in the TCB group and 50 patients in the usual care group. After three months, 36.7% was dependent on ADL in the TCB group compared to 47.1% in the usual care group. Mean number of visits by the CN in the TCB group was 3.8. Although the TCB group had a lower mortality, this study did not find any statistically significant differences in health outcomes and health-care utilisation.

Research limitations/implications

Challenges in the delivery of the programme may have influenced patient outcomes. More research is needed on implementation of evidence-based programmes in smaller research settings. A qualitative phase of the study needs to address these outcomes and explore the perspectives of health professionals and patients on the delivery of the programme.

Originality/value

This study provides valuable information on the transitional care programme in a smaller setting.

Transition of care from hospital to home for older people with chronic diseases: a qualitative study of older patients' and health care providers' perspectives

Background

Transitional care is a critical area of care delivery for older adults with chronic illnesses and complex health conditions. Older adults have high, ongoing care needs during the transition from hospital to home due to certain physical, psychological, social, and caregiving burdens, and in practice, patients' needs are not being met or are receiving transitional care services that are unequal and inconsistent with their actual needs, hindering their safe, healthy transition. The purpose of this study was to explore the perceptions of older adults and health care providers, including older adults, about the transition of care from hospital to home for older patients in one region of China.

Objective

To explore barriers and facilitators in the transition of care from hospital to home for older adults in China from the perspectives of older patients with chronic diseases and healthcare professionals.

Methods

This was a qualitative study based on a semi-structured approach. Participants were recruited from November 2021 to October 2022 from a tertiary and community hospital. Data were analyzed using thematic analysis.

Results

A total of 20 interviews were conducted with 10 patients and 9 medical caregivers, including two interviews with one patient. The older adult/adults patients included 4 men and 6 women with an age range of 63 to 89 years and a mean age of 74.3 ± 10.1 years. The medical caregivers included two general practitioners and seven nurses age range was 26 to 40 years with a mean age of 32.8 ± 4.6 years. Five themes were identified: (1) attitude and attributes; (2) better interpersonal relationships and communication between HCPs and patients; (3) improved Coordination of Healthcare Services Is Needed; (4) availability of resources and accessibility of services; and (5) policy and environment fit. These themes often serve as both barriers and facilitators to older adults' access to transitional care.

Conclusions

Given the fragmentation of the health care system and the complexity of care needs, patient and family-centered care should be implemented. Establish interconnected electronic information support systems; develop navigator roles; and develop competent organizational leaders and appropriate reforms to better support patient transitions.

Investigating areas for improvement in the transition from hospital-to-home for frail older adults: A mixed methods study

Background

The planning and execution of discharge plans to successfully transition frail older adults from hospital-to-home can be a complicated endeavour.

Objective

To identify areas for improvement in the transitional process of frail older adults who were discharged from hospital based, geriatric units to their homes in the community.

Method

A prospective multi-phased mixed methods design was used, and cross-case thematic analysis of Phase 2 data were triangulated with Phase 1 findings.

Results

Thematic analysis findings indicated several related areas of importance within the transitional process: 1) Coordination of discharge; 2) Transition-to-home planning; 3) Home and community care; 4) Following of recommendations; and, 5) Medical follow-up.

Conclusions

Strengthening communication between stakeholders, as well as the implementation of harmonized policies and guidelines are needed to facilitate more consistent care delivery and provide patients and families with information on what to expect during the transitional process.

Improving transitional care communication for older Australians from hospital to home: Co-design of the TRANSITION tool

This study aimed to develop and evaluate a communication tool to guide transitional care for older patients. Using experience-based co-design, a communication tool resulted from the triangulation of data collected from three study phases. From 2015 to 2016, semi-structured interviews and co-design focus groups were undertaken with older patients, carers and healthcare practitioners across acute, rehabilitation and community settings. The evaluation phase, conducted in 2017-2018, involved use of the communication tool by healthcare practitioners in a multidisciplinary care team with older patients in acute care and semi-structured interviews with healthcare practitioners about the acceptability and feasibility of the tool. A total of 103 patients, carers and healthcare practitioners took part. In semi-structured interviews, patients and carers reported needing to become independent in care transitions, which was supported by discussing the transitional care plan with healthcare practitioners. Interviews with healthcare practitioners identified that their need for fast and safe care transitions was supported by team discussion and by engaging patients and carers in their transitional care plan. Co-design focus group participants identified principles guiding transitional care including patient-centred communication. Data collected from semi-structured interviews and co-design focus groups were used to develop a prototype communication tool to guide conversations about discharge care between healthcare practitioners and older patients. Following use, healthcare practitioners reported that the communication tool was feasible and acceptable although some nurses perceived that transitional care was not their role. The communication tool provides an evidence-based resource for ward nurses to support transitional care continuity in multidisciplinary models.

Social care causes of delayed transfer of care (DTOC) from hospital for older people: Unpicking the nuances of 'provider capacity' and 'patient choice'

Unnecessarily prolonged stays in hospitals can have negative impacts on patients and present avoidable costs to health and social care systems. This paper presents the qualitative findings of a multi-methods study of the social care causes of delayed transfers of care (DTOC) for older people in England. The quantitative strand of this study found that DTOC are significantly affected by homecare supply. In this paper, we explore in depth how and why social care capacity factors lead to delays, from the perspectives of those working within the system. We examined the local transfer arrangements in six English local authority (LA) sites that were purposively sampled to include a range of DTOC performance and LA characteristics. Between March and December 2018, 52 professionals involved in arranging or facilitating discharge from hospitals in these sites provided qualitative data, primarily through semi-structured interviews. Topics included discharge teams and processes, strategic issues and perceived causes of delays. The thematic analysis uncovered the nuances behind the causes of DTOC previously categorised broadly as 'provider capacity' and 'patient choice'. In particular, our analysis highlights the lack of fit between available provision and the needs of people leaving hospital (theme 1); workforce inconsistencies (theme 2) and a myth of patient choice (theme 3). We are now at a turning point in the development of policy to reduce DTOC in the English system, with the full implications of a new national discharge to assess programme yet to be seen. Our research shows the significance of the alignment of service capacity, including the type and location of provision, with the needs and preferences of those leaving hospital. As the new system becomes established, attendance to such nuances behind blockages in the system will be more important than ever.

Meanings and Experiences of End-of-Life Patients and Their Family Caregivers in Hospital-to-Home Transitions: A Constructivist Grounded Theory Study

This study explored the meanings and experiences of patients with terminal chronic diseases and their caregivers, who face the imminence of death in the home environment after hospital discharge. The qualitative study used constructivist grounded theory. The participants were individuals with a terminal chronic illness, discharged to home, and their family caregivers. Data were gathered from in-depth interviews and field notes, and a comparative analysis was conducted to identify categories and codes, according to Charmaz's theory. The sample consisted of 21 participants. Three inter-related data categories emerged: "Floating between acceptance and resistance: Perceiving the proximity of death", "Analysing the end from other perspectives: it is in the encounter with death that life is understood" and "Accepting the path: between the love of letting go and the love of wanting to stay". The categories translate the reconstruction of those facing end-of-life occurring in the home environment. It is amid the imminence of death that life gains intensity and talking about the finitude of life configures an opportunity to see life from other perspectives. Giving voice to individuals facing the mishaps of a terminal illness fosters the path to a comfortable death. For health professionals, it is an opportunity to provide structured and humanized care with an ethical attitude, in defence of human dignity.

Improving the safety and experience of transitions from hospital to home: a cluster randomised controlled feasibility trial of the 'Your Care Needs You' intervention versus usual care

Background

The ‘Your Care Needs You’ (YCNY) intervention aims to increase the safety and experience of transitions for older people through greater patient involvement during the hospital stay.

Methods

A cluster randomised controlled feasibility trial was conducted on NHS inpatient wards (clusters) where ≥ 40% of patients were routinely ≥ 75 years. Wards were randomised to YCNY or usual care using an unequal allocation ratio (3:2). We aimed to recruit up to 20 patients per ward. Follow-up included routine data collection and questionnaires at 5-, 30-, and 90-days post-discharge. Eligible patients were ≥ 75 years, discharged home, stayed overnight on participating wards, and could read and understand English.

The trial assessed the feasibility of delivering YCNY and the trial methodology through recruitment rates, outcome completion rates, and a qualitative evaluation. The accuracy of using routinely coded data for the primary outcome in the definitive trial was assessed by extracting discharge information for up to ten nonindividual consenting patients per ward.

Results

Ten wards were randomised (6 intervention, 4 control). One ward withdrew, and two wards were unable to deliver the intervention. Seven-hundred twenty-one patients were successfully screened, and 161 were recruited (95 intervention, 66 control). The patient post-discharge attrition rate was 17.4% (n = 28). Primary outcome data were gathered for 91.9% of participants with 75.2% and 59.0% providing secondary outcome data at 5 and 30 days post-discharge respectively. Item completion within questionnaires was generally high. Post-discharge follow-up was terminated early due to the COVID-19 pandemic affecting 90-day response rates (16.8%). Data from 88 nonindividual consenting patients identified an error rate of 15% when using routinely coded data for the primary outcome. No unexpected serious adverse events were identified.

Most patients viewed YCNY favourably. Staff agreed with it in principle, but ward pressures and organisational contexts hampered implementation. There was a need to sustain engagement, provide clarity on roles and responsibilities, and account for fluctuations in patients’ health, capacity, and preferences.

Conclusions

If implementation challenges can be overcome, YCNY represents a step towards involving older people as partners in their care to improve the safety and experience of their transitions from hospital to home.

Trial registration

ISRCTN: 51154948.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01180-3.

Healthcare consumers' and professionals' perceived acceptability of evidence-based interventions for rural transitional care

BACKGROUND

There is a pressing need for high quality hospital-to-home transitional care in rural communities. Four evidence-based interventions (discharge planning, treatments, warning signs, and physical activity) have the potential to improve rural transitional care. However, there is limited understanding of how the perceptions of healthcare consumers and professionals compare on the acceptability of the interventions. Convergent views on intervention acceptability support implementation, whereas divergent views highlight areas requiring reconciliation prior to implementation.

AIMS

This study compared the acceptability of four evidence-based interventions proposed for rural transitional care, as perceived by healthcare consumers and professionals.

METHODS

A cross-sectional, comparative design was used. The convenience sample included 36 healthcare consumers (20 patients and 16 family caregivers) who had experienced a hospital-to-home transition in the past month and 30 healthcare professionals (29 registered nurses and one nurse practitioner) who provided transitional care in rural Ontario, Canada. Participants were presented with descriptions of the four interventions and completed an established intervention acceptability measure. Presentation of the four intervention descriptions and respective acceptability measures was randomized to control for possible order effects. The perceived overall acceptability of the interventions and their attributes (i.e., effectiveness, appropriateness, risk, and convenience) were compared using independent samples t-tests.

RESULTS

Consumer ratings were consistently higher across all four interventions in terms of overall acceptability as well as effectiveness, appropriateness, and convenience (all p's < .01; effect sizes 0.70-1.13). No significant between-group differences in perceived risk were found.

LINKING EVIDENCE TO ACTION

Contextual and methodological differences may account for variability in ratings, but further research is needed to explore these propositions. The results support future qualitative inquiry targeting professionals to better understand their perspectives on the effectiveness, appropriateness, and convenience of the four interventions.

‘Is my journey destination home?’ Exploring the experiences of older adults who undertake a transition care programme: a qualitative study

Transition care programmes (TCP) provide older adults with goal-oriented rehabilitation after hospitalisation. However, limited research has focused on understanding older adults' experiences when undertaking TCP. Using a phenomenological approach, we explored the lived experience of older adults undertaking a TCP at a transition care facility in Australia. A purposive sample (N = 33 participants: 16 older adults, four family members and 13 staff) was recruited. Semi-structured interviews were undertaken at three time-points during admission and inductive thematic analysis was utilised. Older adults reflected on their TCP experiences through an emotional lens through which they deliberated, ‘is my destination home?’ Fear of losing independence and uncertainty about their discharge destination strongly influenced older adults' perspectives regarding their TCP experience. Emotional responses, both positive and negative, were influenced by expectations prior to admission, level of family support and staff behaviour. Staff and family concurred that many older adults were confused about their admission to the facility and initially were unprepared to engage in the rehabilitation provided. Older adults experienced TCP as a time of great uncertainty and feared the unknown when discharged from hospital to transition care. They expressed grief at the loss of existing life roles and anxiety about the possibility of being unable to return home. Health professionals need to inform and tailor rehabilitation for older adults to better support this transient time of life.

Designing the Ideal Patient Navigation Program for Older Adults with Complex Needs: A Qualitative Exploration of the Preferences of Key Informants

Navigating the healthcare system is complex. Many older adults and their family members report sub-optimal outcomes when transitioning from hospital to home. Patient navigation has been introduced as a model of care to help improve hospital to home transitions and to better integrate care across care environments. There are no best-practice guidelines for designing a patient navigation program for older adults with complex needs. This qualitative descriptive study interviewed 38 healthcare professionals to determine key characteristics of the "ideal" patient navigator program. Thematic analysis revealed four themes describing key components of an ideal patient navigator program for older adults with complex needs: (1) Easy accessibility and open communication amongst staff; (2) flexible eligibility requirements; (3) characteristics of the patient navigator; and (4) appropriate program size and duration. We suggest directions for future research, program design, and implementation considers to improve patient navigation for older adults and their family caregivers.

Doing involvement: A qualitative study exploring the 'work' of involvement enacted by older people and their carers during transition from hospital to home

CONTEXT

Being involved in one's care is prioritised within UK healthcare policy to improve care quality and safety. However, research suggests that many older people struggle with this.

DESIGN

We present focused ethnographic research exploring older peoples' involvement in healthcare from hospital to home.

RESULTS

We propose that being involved in care is a dynamic form of labour, which we call 'involvement work' (IW). In hospital, many patients 'entrust' IW to others; indeed, when desired, maintaining control, or being actively involved, was challenging. Patient and professionals' expectations, alongside hospital processes, promoted delegation; staff frequently did IW on patients' behalf. Many people wanted to resume IW postdischarge, but struggled because they were out of practice.

DISCUSSION

Preference and capacity for involvement was dynamic, fluctuating over time, according to context and resource accessibility. The challenges of resuming IW were frequently underestimated by patients and care providers, increasing dependence on others post-discharge and negatively affecting peoples' sense and experience of (in)dependence.

CONCLUSIONS

A balance needs to be struck between respecting peoples' desire/capacity for non-involvement in hospital while recognising that 'delegating' IW can be detrimental. Increasing involvement will require patient and staff roles to be reframed, though this must be done acknowledging the limits of patient desire, capability,and resources. Hospital work should be (re)organised to maximise involvement where possible and desired.

PATIENT/PUBLIC CONTRIBUTION

Our Patient and Public Involvement and Engagement Panel contributed to research design, especially developing interview guides and patient-facing documentation. Patients were key participants within the study; it is their experiences represented.

Knowledge and Power Relations in Older Patients' Communication About Medications Across Transitions of Care

Communicating about medications across transitions of care is a challenging process for older patients. In this article, we examined communication processes between older patients, family members, and health professionals about managing medications across transitions of care, focusing on older patients' experiences. A focused ethnographic design was employed across two metropolitan hospitals. Data collection methods included interviews, observations, and focus groups. Following thematic analysis, data were analyzed using Fairclough's Critical Discourse Analysis and Medication Communication Model. Older patients' medication knowledge and family members' advocacy challenged unequal power relations between clinicians and patients and families. Doctors' use of authoritative discourse impeded older patients' participation in the medication communication. Older patients perceived that nurses' involvement in medication communication was limited due to their task-related routines. To reduce the unequal power relations, health professionals should be more proactive in sharing information about medications with older patients across transitions of care.

Transitional Care Management from Emergency Services to Communities: An Action Research Study

In recent years, nurses have developed projects in the area of hospital to community transition. The objective of the present study was to analyze the transitional care offered to elderly people after they used emergency services and were discharged to return to the community. The action research method was chosen. The participants were nurses, elderly people 70 years old or older, and their caregivers. The study was carried out from October 2018 to August 2019. The data were collected by means of semi-structured interviews with the nurses, analysis of medical records, participatory observation, phone calls to the elderly people and caregivers, and team meetings. The qualitative data were submitted to Bardin’s content analysis. Statistical treatment was carried out by applying SPSS version 23.0. The institution’s research ethics committee approved the research. Only 31.4% of the sample experienced care continuity after discharge, and the rate of readmission to emergency services during the first 30 days after discharge was 33.4%. The referral letters lacked data on information provided to patients or caregivers, and nurses mentioned difficulties in communication between care levels, as well as obstacles to teamwork; they also mentioned that the lack of health policies and clinical rules to formalize transitional care between the hospital and the community perpetuated non-coordination of care between the two contexts. The low level of literacy of patients and their relatives are mentioned as a cause for not understanding the information regarding seeking primary health care services and handing the discharge letter. It was concluded that there is an urgent need to mobilize health teams toward action in the patients’ process of returning home, and this factor must be taken into account in care planning.

Assessing the influence of patient language preference on 30 day hospital readmission risk from home health care: A retrospective analysis

BACKGROUND

In home health care, language barriers are understudied. Language barriers between patients and providers are known to affect a variety of patient outcomes. How a patient's language preference influences hospital readmission risk from home health care has yet to be determined.

OBJECTIVE

To determine if home care patients' language preference is associated with their risk for hospital readmission from home health care within 30 days of hospital discharge.

DESIGN

Retrospective cross-sectional study of hospital readmissions from an urban home health care agency's administrative records and the national electronic home health care record for the United States, captured between 2010 and 2015.

SETTING

New York City, New York, USA.

PARTICIPANTS

The dataset comprised 90,221 post-hospitalization patients and 6.5 million home health care visits.

METHODS

First, a Chi-square test was used to determine if there were significant differences in crude readmission rates based on language group. Inverse probability of treatment weighting was used to adjust for significant differences in known hospital readmission risk factors between to examine all-cause hospital readmission during a home health care stay. The final matched sample included 87,561 patients with a language preference of English, Spanish, Russian, Chinese, or Korean. English-speaking patients were considered the comparison group to the non-English speaking patients. A Marginal Structural Model was applied to estimate the impact of non-English language preference against English language preference on rehospitalization. The results of the marginal structural model were expressed as an odds ratio of likelihood of readmission to the hospital from home health care.

RESULTS

Home health patients with a non-English language preference had a higher hospital readmission risk than English-speaking patients. Crude readmission rate for the limited English proficiency patients was 20.4% (95% CI, 19.9-21.0%) overall compared to 18.5% (95% CI, 18.7-19.2%) for English speakers (p < 0.001). Being a non-English-speaking patient was associated with an odds ratio of 1.011 (95% CI, 1.004-1.018) in increased hospital readmission rates from home health care (p = 0.001). There were also statistically significant differences in readmission rate by language group (p < 0.001), with Korean speakers having the lowest rate and Spanish speakers having the highest, when compared to English speakers.

CONCLUSIONS

People with a non-English language preference have a higher readmission rate from home health care. Hospital and home healthcare agencies may need specialized care coordination services to reduce readmission risk for these patients. Tweetable abstract: A new US-based study finds that home care patients with language barriers are at higher risk for hospital readmission.

The impact of social network change and health decline: a qualitative study on experiences of older adults who are ageing in place

Background

Older adults prefer to age in place. Social network change and health decline challenge ageing in place, as stressors that make age-related advantages disappear. The aim of this study was to explore social network change and health decline and its impact on older adults who are ageing in place.

Method

In-depth interviews (n = 16) were conducted with older adults who were ageing in place and who were experiencing health decline and social network change. Procedures for grounded theory building were followed to analyse the interviews with respondents who were discharged from the hospital less than 4 months ago (n = 7). Narrative analysis was conducted to reach a deeper understanding of the expected complexity of experiences of this targeted sample.

Results

Results encompass a typology with four types of impact: A. Sneak preview of old age, B. Disruptive transition into old age, C. Drastically ageing, and D. Steadily ageing. Additionally, indications were found that older adults should be able to move along the four types of impact and ideally could end up in quartile D, experiencing little or no impact at all (anymore).

Conclusion

The results present an optimistic view on the possibilities of older adults to continue ageing in place despite experiencing unavoidable and uncontrollable stressors in life. Also, the results provide leads for practice, to develop an action perspective for home care nurses and gerontological social workers to determine and reduce the impact of social network change and health decline on older adults who are ageing in place. Suggestions for further research would be to unravel how to detect temporal setbacks in successful ageing in place.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02385-6.

Examining the course of transitions from hospital to home-based palliative care: A mixed methods study

BACKGROUND

Hospital-to-home transitions in palliative care are fraught with challenges. To assess transitions researchers have used patient reported outcome measures and qualitative data to give unique insights into a phenomenon. Few measures examine care setting transitions in palliative care, yet domains identified in other populations are likely relevant for patients receiving palliative care.

AIM

Gain insight into how patients experience three domains, discharge readiness, transition quality, and discharge-coping, during hospital-to-home transitions.

DESIGN

Longitudinal, convergent parallel mixed methods study design with two data collection visits: in-hospital before and 3-4 weeks after discharge. Participants completed scales assessing discharge readiness, transition quality, and post discharge-coping. A qualitative interview was conducted at both visits. Data were analyzed separately and integrated using a merged transformative methodology, allowing us to compare and contrast the data.

SETTING AND PARTICIPANTS

Study was set in two tertiary hospitals in Toronto, Canada. Adult inpatients (n = 25) and their caregivers (n = 14) were eligible if they received a palliative care consultation and transitioned to home-based palliative care.

RESULTS

Results were organized aligning with the scales; finding low discharge readiness (5.8; IQR: 1.9), moderate transition quality (66.7; IQR: 33.33), and poor discharge-coping (5.0; IQR: 2.6), respectively. Positive transitions involved feeling well supported, managing medications, feeling well, and having healthcare needs met. Challenges in transitions were feeling unwell, confusion over medications, unclear healthcare responsibilities, and emotional distress.

CONCLUSIONS

We identified aspects of these three domains that may be targeted to improve transitions through intervention development. Identified discrepancies between the data types should be considered for future research exploration.

The Potential of AI in Care Optimization: Insights from the User-Driven Co-Development of a Care Integration System

Transitions from one level of care to another are complex processes that pose medical and organizational risks and depend on care integration between different providers. This qualitative study investigated user experiences with an existing digital system for care integration between hospitals and nursing homes, and the potential of artificial intelligence to contribute to its optimization. The findings reveal challenges regarding (a) untimely information, (b) irrelevant information, (c) confusing information, (d) missing information, (e) information overload, and (f) information multiplicity. Artificial intelligence could address these by (i) identifying and verifying low-quality information, (ii) targeting information for different user groups, (iii) visually summarizing relevant information, and (iv) jointly presenting multiple versions. The implications of these findings extend beyond the context of care integration, presenting empirical evidence for the importance of qualitative health research in, and a model for, determining the scope and design of future artificial intelligence solutions to optimize (health)care processes.

Crossing knowledge boundaries: health care providers' perceptions and experiences of what is important to achieve more person-centered patient pathways for older people

BACKGROUND

Improving the transitional care of older people, especially hospital-to-home transitions, is a salient concern worldwide. Current research in the field highlights person-centered care as crucial; however, how to implement and enact this ideal in practice and thus achieve more person-centered patient pathways remains unclear. The aim of this study was to explore health care providers' (HCPs') perceptions and experiences of what is important to achieve more person-centered patient pathways for older people.

METHODS

This was a qualitative study. We performed individual semistructured interviews with 20 HCPs who participated in a Norwegian quality improvement collaborative. In addition, participant observation of 22 meetings in the quality improvement collaborative was performed.

RESULTS

A thematic analysis resulted in five themes which outline central elements of the HCPs' perceptions and experiences relevant to achieving more person-centered patient pathways: 1) Finding common ground through the mapping of the patient journey; 2) the importance of understanding the whole patient pathway; 3) the significance of getting to know the older patient; 4) the key role of home care providers in the patient pathway; and 5) ambiguity toward checklists and practice implementation.

CONCLUSIONS

The findings can assist stakeholders in understanding factors important to practicing person-centered transitional care for older people. Through collaborative knowledge sharing the participants developed a more shared understanding of how to achieve person-centered patient pathways. The importance of assuming a shared responsibility and a more holistic understanding of the patient pathway by merging different ways of knowing was highlighted. Checklists incorporating the What matters to you? question and the mapping of the patient journey were important tools enabling the crossing of knowledge boundaries both between HCPs and between HCPs and the older patients. Home care providers were perceived to have important knowledge relevant to providing more person-centered patient pathways implying a central role for them as knowledge brokers during the patient's journey. The study draws attention to the benefits of focusing on the older patients' way of knowing the patient pathway as well as to placing what matters to the older patient at the heart of transitional care.

Palliative care transitions from acute care to community-based care: A qualitative systematic review of the experiences and perspectives of health care providers

BACKGROUND

Transitioning from the hospital to community is a vulnerable point in patients' care trajectory, yet little is known about this experience within the context of palliative care. While some studies have examined the patient and caregiver experience, no study to date has synthesized the literature on the healthcare provider's perspective on their role and experience facilitating these transitions.

AIM

The purpose of this systematic review was to understand the experience and perspective of healthcare providers who support the transition of patients receiving palliative care as they move from acute care to community settings.

DESIGN

A qualitative systematic review of studies using thematic analysis as outlined by Thomas and Harden. PROSPERO: ID # CRD42018109662.

DATA SOURCES

We searched four databases: MEDLINE, Embase, ProQuest and CINAHL for studies published in English from 1995 until May 22, 2020. Four reviewers screened records using the following selection criteria: (1) peer-reviewed empirical study, (2) adult sample, (3) qualitative study design, (4) perspective of healthcare providers, and (5) included a component of transitions between acute to community-based palliative care. Study findings were analyzed using thematic analysis which entailed: (1) grouping the findings into recurring themes; (2) iteratively referring back to the articles to obtain nuances of the theme and quotations; and (3) defining and solidifying the themes.

RESULTS

Overall 1,791 studies were identified and 15 met inclusion criteria. Studies were published recently (>2015, n = 12, 80%) and used a range of qualitative methods including semi-structured interviews, focus groups, and field interviews. Three core themes related to the role and experience of healthcare providers were identified: (1) assessing and preparing for transition; (2) organizing and facilitating the logistics of transition; and (3) coordinating and collaborating transitional care across sectors. The majority of studies focused on the discharge process from acute care; there was a lack of studies exploring the experiences of healthcare providers in the community who receive patients from acute care and provide them with palliative care at home.

CONCLUSION

This review identified studies from a range of relatively high-income countries that included a diverse sample of healthcare providers. The results indicate that healthcare providers experience multiple complex roles during the transition facilitation process, and future research should examine how to better assist clinicians in supporting these transitions within the context of palliative care provision.

Exploring the dimensions of patient experience for community-based care programmes in a multi-ethnic Asian context

Introduction

The aim of this study is to explore patients’ experiences with community-based care programmes (CCPs) and develop dimensions of patient experience salient to community-based care in Singapore. Most countries like Singapore are transforming its healthcare system from a hospital-centric model to a person-centered community-based care model to better manage the increasing chronic disease burden resulting from an ageing population. It is thus critical to understand the impact of hospital to community transitions from the patients’ perspective. The exploration of patient experience will guide the development of an instrument for the evaluation of CCPs for quality improvement purposes.

Methods

A qualitative exploratory study was conducted where face-to-face in-depth interviews were conducted using a purposive sampling method with patients enrolled in CCPs. In total, 64 participants aged between 41 to 94 years were recruited. A deductive framework was developed using the Picker Patient Experience instrument to guide our analysis. Inductive coding was also conducted which resulted in emergence of new themes.

Results

Our findings highlighted eight key themes of patient experience: i) ensuring care continuity, ii) involvement of family, iii) access to emotional support, vi) ensuring physical comfort, v) coordination of services between providers, vi) providing patient education, vii) importance of respect for patients, and viii) healthcare financing.

Conclusion

Our results demonstrated that patient experience is multi-faceted, and dimensions of patient experience vary according to healthcare settings. As most patient experience frameworks were developed based on a single care setting in western populations, our findings can inform the development of a culturally relevant instrument to measure patient experience of community-based care for a multi-ethnic Asian context.

'There was no preamble': Comparing the Transition from Hospital to Home in Different Care Settings

Our qualitative descriptive study compared how older patients and their informal caregivers experienced the care transition from acute care or rehabilitation to home. We recruited patients 65 years of age or older, or their informal caregivers, from in-patient units within acute care hospitals and rehabilitation facilities to participate in semi-structured interviews. We identified emergent themes via thematic analysis. In all, 16 patients and four patient caregivers participated. Across all care settings, caregivers were integral in facilitating the transition as well as experiencing variable discharge preparation, health care providers' optimizing transitions, and missed care and medication discrepancies at transition points. Orthopedic and rehabilitation patients more commonly voiced prior transition experiences in discharge preparation, including having to unexpectedly coordinate and wait for outpatient services. Differing responses between acute care and orthopedic settings suggest that transitional care practices and policies favor an individualized approach that considers patients' previous experiences, needs, and care expectations.

Transitional care to caregivers of dependent older people: an integrative literature review

OBJECTIVE

To identify the needs of caregivers of dependent older people related to self-care in the transition from hospital to home.

METHODS

Integrative literature review that followed a predefined protocol, carried out from March to May 2019 in the platforms EBSCO, B-On, Scopus, Web of Science, and Joanna Briggs Institute. Descriptors and eligibility criteria were defined for the bibliographic sample, which was ten articles. The search was limited to articles published between 2015 and 2019 to guarantee evidence topicality.

RESULTS

The needs of caregivers related to transitional care can be grouped into five categories: needs in the transition into the role of caregiver; needs related to self-care of caregivers themselves; health needs; economic needs; and social and collective needs.

FINAL CONSIDERATIONS

The work developed by nurses regarding transitional care of caregivers must have two focuses: managing care provided to dependent older people and managing the needs of caregivers and the care offered to them.

Effectiveness of individualised nutritional care plans to reduce malnutrition during hospitalisation and up to 3 months post-discharge: a systematic scoping review

OBJECTIVES

The prevalence of malnutrition after hospitalisation is reported to be 20%-45%, which may lead to adverse outcomes, as malnutrition increases the risk of complications, morbidity, mortality and loss of function. Improving the quality of nutritional treatment in hospitals and post-discharge is necessary, as hospital stays tend to be short. We aimed to identify and map studies that assess the effectiveness of individualised nutritional care plans to reduce malnutrition during hospitalisation and for the first 3 months post-discharge.

DESIGN

This was a systematic scoping review.

METHODS

We systematically searched for all types of studies in the following databases: EMBASE, MEDLINE via PubMed, and the Cumulative Index to Nursing and Allied Health Literature, with no restriction on data or publication language. We also reviewed the reference lists of the included studies. The abstracts and full articles were simultaneously screened by two independent reviewers. Differences of opinion were discussed among the two investigators, and a third reviewer assisted with the discussion until consensus was reached. Studies in which the patients received an individual nutritional care plan related to their hospital stay and were followed up post-discharge were included. We then conducted a thematic content analysis of the extracted literature.

RESULTS

Nine randomised controlled trial studies met the inclusion criteria: six were conducted in Scandinavian countries. All studies were mainly conducted among elderly patients (mean ages varied from 75 to 88 years). The review studies measured 10 different outcomes; the most common outcomes were nutritional status and readmission. Six studies reported one or more significant positive intervention effect. Inconsistent results were identified for four outcome variables.

CONCLUSIONS

Individualised nutritional care plans and follow-up home visits might improve patients' nutritional status. However, there is need for a systematic review that assesses study quality and extends the time to 6 months post-discharge.

Effects of interorganisational information technology networks on patient safety: a realist synthesis

OBJECTIVE

Health services in many countries are investing in interorganisational networks, linking patients' records held in different organisations across a city or region. The aim of the systematic review was to establish how, why and in what circumstances these networks improve patient safety, fail to do so, or increase safety risks, for people living at home.

DESIGN

Realist synthesis, drawing on both quantitative and qualitative evidence, and including consultation with stakeholders in nominal groups and semistructured interviews.

ELIGIBILITY CRITERIA

The coordination of services for older people living at home, and medicine reconciliation for older patients returning home from hospital.

INFORMATION SOURCES

17 sources including Medline, Embase, CINAHL, Cochrane Library, Web of Science, ACM Digital Library, and Applied Social Sciences Index and Abstracts.

OUTCOMES

Changes in patients' clinical risks.

RESULTS

We did not find any detailed accounts of the sequences of events that policymakers and others believe will lead from the deployment of interoperable networks to improved patient safety. We were, though, able to identify a substantial number of theory fragments, and these were used to develop programme theories.There is good evidence that there are problems with the coordination of services in general, and the reconciliation of medication lists in particular, and it indicates that most problems are social and organisational in nature. There is also good evidence that doctors and other professionals find interoperable networks difficult to use. There was limited high-quality evidence about safety-related outcomes associated with the deployment of interoperable networks.

CONCLUSIONS

Empirical evidence does not currently justify claims about the beneficial effects of interoperable networks on patient safety. There appears to be a mismatch between technology-driven assumptions about the effects of networks and the sociotechnical nature of coordination problems.

PROSPERO REGISTRATION NUMBER

CRD42017073004.

The effects of interoperable information technology networks on patient safety: a realist synthesis

Background

Interoperable networks connect information technology systems of different organisations, allowing professionals in one organisation to access patient data held in another one. Health policy-makers in many countries believe that they will improve the co-ordination of services and, hence, the quality of services and patient safety. To the best of our knowledge, there have not been any previous systematic reviews of the effects of these networks on patient safety.

Objectives

The aim of the study was to establish how, why and in what circumstances interoperable information technology networks improved patient safety, failed to do so or increased safety risks. The objectives of the study were to (1) identify programme theories and prioritise theories to review; (2) search systematically for evidence to test the theories; (3) undertake quality appraisal, and use included texts to support, refine or reject programme theories; (4) synthesise the findings; and (5) disseminate the findings to a range of audiences.

Design

Realist synthesis, including consultation with stakeholders in nominal groups and semistructured interviews.

Settings and participants

Following a stakeholder prioritisation process, several domains were reviewed: older people living at home requiring co-ordinated care, at-risk children living at home and medicines reconciliation services for any patients living at home. The effects of networks on services in health economies were also investigated.

Intervention

An interoperable network that linked at least two organisations, including a maximum of one hospital, in a city or region.

Outcomes

Increase, reduction or no change in patients’ risks, such as a change in the risk of taking an inappropriate medication.

Results

We did not find any detailed accounts of the ways in which interoperable networks are intended to work and improve patient safety. Theory fragments were identified and used to develop programme and mid-range theories. There is good evidence that there are problems with the co-ordination of services in each of the domains studied. The implicit hypothesis about interoperable networks is that they help to solve co-ordination problems, but evidence across the domains showed that professionals found interoperable networks difficult to use. There is insufficient evidence about the effectiveness of interoperable networks to allow us to establish how and why they affect patient safety.

Limitations

The lack of evidence about patient-specific measures of effectiveness meant that we were not able to determine ‘what works’, nor any variations in what works, when interoperable networks are deployed and used by health and social care professionals.

Conclusions

There is a dearth of evidence about the effects of interoperable networks on patient safety. It is not clear if the networks are associated with safer treatment and care, have no effects or increase clinical risks.

Future work

Possible future research includes primary studies of the effectiveness of interoperable networks, of economies of scope and scale and, more generally, on the value of information infrastructures.

Study registration

This study is registered as PROSPERO CRD42017073004.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 40. See the NIHR Journals Library website for further project information.

Transitional 'hospital to home' care of older patients: healthcare professionals' perspectives

BACKGROUND

Transitional care is a key area of care provision to older people with chronic and complex health conditions and is associated with the quality of care delivered in the healthcare system.

AIMS

This study aimed to explore the perspectives of healthcare providers, including nurses and physicians, regarding transitional care from hospital to home in an urban area of Turkey.

METHODS

A qualitative study using a thematic analysis method was carried out. In-depth semi-structured interviews were held with eight clinical nurses and five general physicians involved in the provision of healthcare services to older patients in the transitional care process from hospital to home.

FINDINGS

The thematic analysis of in-depth semi-structured interviews with 13 healthcare professionals led to the development of the following themes: 'uninterrupted chain of care transfer', 'commitment to meet patient's needs' and 'support and removing ambiguities'.

CONCLUSIONS

Key factors impacting on the quality and safety of transitional care and continuity of healthcare are communication and collaboration between healthcare staff and settings, and older patients' as well as family caregivers' awareness and their feelings of responsibility towards the continuity of care at home.

Perceived Quality of Care Transitions between Hospital and the Home in People with Stroke

OBJECTIVES

To explore the perceived quality of care transitions from hospital to the home with referral to subsequent rehabilitation in the home, and factors associated with low perceived quality, in people with stroke.

DESIGN

Observational study.

SETTING AND PARTICIPANTS

Eligible were patients with a suspected acute stroke admitted to 1 of 4 inpatient hospital units in the Stockholm region and discharged home with referral to a neurorehabilitation team in primary care.

METHODS

Data on perceived quality of care transition was collected with the Care Transition Measure (CTM-15) 1 week after discharge. Additional data were mainly retrieved from medical records. To analyze difference in mean total score of the CTM-15 between participants' characteristics, length of hospital stay, disease-related data, and functioning, the Mann-Whitney U test and independent sample t test were used for dichotomized variables and 1-way analysis of variance and the Tukey post hoc test for variables with more than 2 groups. To analyze differences between participants with low and high perceived quality per item, univariable regression analyses were performed. Thereafter, multivariable regression models were created to explore associations between low perceived quality and the independent variables.

RESULTS

Mean age of the 189 participants was 75 years and 91% had a mild or very mild stroke. The majority perceived most areas of the care transition to be of high quality. Nevertheless, several areas for improvement were identified. People with a more severe stroke perceived the quality of the care transition to be lower in comparison with those with a mild stroke. The association was weak between patient or clinical characteristics and the perceived quality.

CONCLUSION AND IMPLICATIONS

Our findings suggest that preparation for discharge and information and support for self-management postdischarge should be enhanced in the referral-based care transition after stroke. Special attention should be given to people with severe stroke.

Does health and social care provision for the community dwelling older population help to reduce unplanned secondary care, support timely discharge and improve patient well-being? A mixed method meta-review of systematic reviews

Background: This study aimed to identify and examine systematic review evidence of health and social care interventions for the community-dwelling older population regarding unplanned hospital admissions, timely hospital discharge and patient well-being. Methods: A meta-review was conducted using Joanna Briggs and PRISMA guidance. A search strategy was developed: eight bibliographic medical and social science databases were searched, and references of included studies checked. Searches were restricted to OECD countries and to systematic reviews published between January 2013-March 2018. Data extraction and quality appraisal was undertaken by one reviewer with a random sample screened independently by two others. Results: Searches retrieved 21,233 records; using data mining techniques, we identified 8,720 reviews. Following title and abstract and full-paper screening, 71 systematic reviews were included: 62 quantitative, seven qualitative and two mixed methods reviews. There were 52 reviews concerned with healthcare interventions and 19 reviews concerned with social care interventions. This meta-review summarises the evidence and evidence gaps of nine broad types of health and social care interventions. It scrutinises the presence of research in combined health and social care provision, finding it lacking in both definition and detail given. This meta-review debates the overlap of some of the person-centred support provided by community health and social care provision. Research recommendations have been generated by this process for both primary and secondary research. Finally, it proposes that research recommendations can be delivered on an ongoing basis if meta-reviews are conducted as living systematic reviews. Conclusions: This meta-review provides evidence of the effect of health and social care interventions for the community-dwelling older population and identification of evidence gaps. It highlights the lack of evidence for combined health and social care interventions and for the impact of social care interventions on health care outcomes. Registration: PROSPERO ID CRD42018087534; registered on 15 March 2018.

Goals of care or goals of life? A qualitative study of clinicians' and patients' experiences of hospital discharge using Patient-Oriented Discharge Summaries (PODS)

Background

Recognizing the need for improved communication with patients at the point of hospital discharge, a group of clinicians, patients, and designers in Toronto, Canada collaborated to develop a standardized tool known as the Patient-Oriented Discharge Summary (PODS). Although quantitative results suggest PODS helps mitigate gaps in knowledge, a qualitative inquiry from the clinician and patient perspective of psychiatric hospital discharge using PODS has not been widely explored. Our aim was to explore clinicians’ and patients’ experiences with PODS.

Methods

We used a qualitative thematic analysis to explore clinicians’ (n = 10) and patients’ (n = 6) experiences with PODS. We used convenience sampling to identify and invite potential participants at the Center for Addiction and Mental Health in Toronto, Canada to participate in semi-structured interviews between February 2019 and September 2019. Data were analyzed using a thematic analysis approach to develop descriptive themes.

Results

Emerging themes from the data between clinicians and patients were both different and complementary. Clinicians described PODS using the concept of “goals of care.” They relayed their experiences with PODS as a discrete event and emphasized its role in meeting their “goals of care” for discharge planning. Patients provided more of a “goals of life” perspective on recovery. They characterized PODS as only one facet of their recovery journey and not necessarily as a discrete or memorable event. Patients focused on their outcomes post-discharge and situated their experiences with PODS through its relation to their overall recovery.

Conclusions

PODS was experienced differently by clinicians and patients. Clinicians experienced PODS as helpful in orienting them to the fulfillment of goals of care. Patients did not experience PODS as a particularly memorable intervention. Due to the information advantage that clinicians have about PODS, it is not surprising that clinicians and patients experienced the PODS differently. This study expanded our understanding of hospital discharge from clinicians and patients perspectives, and suggests that there are additional areas that need improvement.

Rural gerontological health: Emergent questions for research, policy and practice

This article explores what can be learned from the evolution of rural gerontology as a field of study to inform a more critical approach to the health of rural older adults. To counter the prevailing essentialism of highlighting the rural health disparities faced by older adults, there is a need to expand rural gerontological health research beyond deficit and medicalized understandings of health in rural communities. We argue that appreciating the interplay between unique health experiences, the complexity of the rural context and the continuum of older adult care is an important next step to foster advances in the field. Emergent questions for research, policy and practice are discussed and new directions for rural gerontological health are proposed.

Standardized Hospital Discharge Communication for Patients With Pressure Injury: A Quasi-experimental Trial

PURPOSE

To determine if improved communication between certified wound care nurses and home health nurses, through use of standardized electronic wound care order sets and discharge instructions, decreased delay in treatment and 30-day readmission rates and improved wound healing for patients discharged to home with pressure injuries.

DESIGN

Quasi-experimental, nonequivalent group trial.

SUBJECTS AND SETTING

Cognitively intact adult patients hospitalized in the Midwestern United States with a stage 2 or higher pressure injury discharged to home care services.

METHODS

We revised the electronic medical record to include an adapted, standardized version of the Project Re-Engineered Discharge wound care order set that included specific wound care instructions for use following discharge to home care. Medical records of 12 patients were reviewed prior to the change and 9 records were reviewed postchange for information about initiation of care, wound healing, and 30-day readmission. The Pressure Ulcer Scale of Healing tool was used to evaluate wound healing.

RESULTS

Time to initiation of treatment was 2.4 days for the control group and 1.6 days for the intervention group. Missing documentation made it difficult to evaluate the control group, as 73% of all wound measurements were missing from the electronic medical record. Use of the standardized wound care order set resulted in 100% of wound care orders and 92% of discharge instructions being present in the intervention group's electronic medical record at the time of hospital discharge. There was no statistically significant difference between control and intervention group's Pressure Ulcer Scale of Healing scores for any postdischarge measurement or in 30-day readmission rates.

CONCLUSIONS

The new standardized wound care order sets at the time of discharge did increase adherence to time to implementation and documentation of executing wound care orders by home care nurses. Further research of standardized order sets is needed to determine the impact on improving patient outcomes.

'Handing over to the patient': A FRAM analysis of transitional care combining multiple stakeholder perspectives

INTRODUCTION

The period following discharge can present risks for older adults. Most research has focused on hospital discharge with less attention paid to on-going care needs. Despite evidence that patients undertake 'invisible work' to improve care safety, their reported willingness to be involved in care, and the consensus that successful transitions interventions include patient involvement, in reality, this is variable. Further, little research has viewed transitional care as a 'system', with gaps, interdependencies and variability across settings, nor the role of patients and families in supporting the system resilience.

RESEARCH OBJECTIVES

1) model transitional care from multiple perspectives using the Functional Resonance Analysis Method (FRAM); 2) use the model to develop a theory of change to support intervention development.

METHOD

We drew data from two studies: i) exploring the perspective of older adults across transitional care, and ii) exploring how health services experience transitional care. We employed the FRAM to develop a model of transitional care, with a system boundary spanning an older patient's admission to hospital, through to thirty days post-discharge.

FINDINGS

Modelling transitional care from multiple perspectives was challenging. 27 functions were identified with interdependencies between hospital-based functions and patient-led functions once home, the success of which may impact on transitions 'outcomes' (e.g. safety events, readmissions). The model supported development of a theory of change, to guide future intervention development.

CONCLUSIONS

Supporting certain patient-facing upstream hospital functions (e.g. encouraging mobility, supporting a better understanding of medication and condition), may lead to improved outcomes for patients following hospital discharge.

Communication and Coordination Processes Supporting Integrated Transitional Care: Australian Healthcare Practitioners' Perspectives

Introduction:

Although a large body of research has identified effective models of transitional care, questions remain about the optimal translation of this knowledge into practice. In Australia, the introduction of a model of consumer-directed care uniquely challenges the practice of integrated care transitions for older adults. This study aimed to identify strengths and weaknesses in transitional care for older adults in an Australian setting by describing healthcare practitioners’ experiences of care provision.

Methods:

The study used a qualitative design in two phases: 1) semi-structured interviews, 2) one focus group. The setting comprised one public health network and five community services in urban Australia. In Phase 1, health practitioners across settings were interviewed about their experience of transitional care. Phase 2 sought feedback about the Phase 1 findings from different practitioners. All data were thematically analysed.

Findings:

In Phase 1), 48 healthcare practitioners were interviewed across multiple settings. Few participants were aware of the introduction of consumer-directed care in community aged care. Four main themes were identified: ‘Rapid and safe care transition’, ‘Discussing as a team’, ‘Questioning the discharge’, and ‘Engaging patients and carers’. In Phase 2), seven participants from different settings reviewed and endorsed the findings from Phase 1.

Discussion and conclusions:

Findings indicate that healthcare practitioners use a range of communication and coordination processes in optimising integrated transitional care. Although participants involved their patients in transitional care planning, most participants were unaware of the recent implementation of consumer-directed care. In contexts of community-based care shaped by multidisciplinary, sub-acute and CDC models, care integration must focus on improved communication with patients and carers to ascertain their needs and to support their increased responsibility in their care transitions.

What matters when asking, "what matters to you?" - perceptions and experiences of health care providers on involving older people in transitional care

BACKGROUND

Transitional care for older chronically ill people is an important area for healthcare quality improvement. A central goal is to involve older people more in transitional care and make care more patient-centered. Recently, asking, "What matters to you?" (WMTY) has become a popular way of approaching the implementation of patient-centered care. The aim of this study was to explore health care providers' perceptions and experiences regarding the question of WMTY in the context of improving transitional care for older, chronically ill persons.

METHODS

The data comprise semi-structured individual interviews with 20 health care providers (HCPs) who took part in a Norwegian quality improvement collaborative, three key informant interviews, and observations of meetings in the quality improvement collaborative. We used a thematic analysis approach.

RESULTS

Three interrelated themes emerged from the analysis: WMTY is a complex process that needs to be framed competently; framing WMTY as a functional approach; and framing WMTY as a relational approach. There was a tension between the functional and the relational approach. This tension seemed to be based in different understandings of the purpose of asking the WMTY question and the responsibility that comes with asking it.

CONCLUSIONS

WMTY may appear as a simple question, but using it in everyday practice is a complex process, which requires professional competence. When seen in terms of a patient-centered goal process, the challenge of competently eliciting older people's personal goals and transferring these goals into professional action becomes evident. An important factor seems to be how HCPs regard the limits of their responsibility in relation to giving care within the larger frame of the patient's life project. Factors in the organizational and political context also seem to influence substantially how HCPs approach older patients with the WMTY question.

Evaluation of the TRANSITION tool to improve communication during older patients' care transitions: Healthcare practitioners' perspectives

AIMS

To evaluate healthcare practitioners' perceptions of the feasibility and acceptability of a communication tool, entitled the TRANSITION tool, to communicate with older patients during transition from acute care to a community setting.

BACKGROUND

Transitional care for older patients is challenging due to their complex care needs and rapid care transitions. Research has identified effective models of transitional care. However, optimal communication between healthcare practitioners and older patients remains under-investigated.

DESIGN

Exploratory descriptive qualitative design.

METHODS

The methods are reported using the Consolidated Criteria for Reporting Qualitative Studies checklist. The setting comprised two acute medical wards in an urban hospital in Australia. Twenty-two nursing and allied healthcare practitioners used the TRANSITION tool to guide communication about transitional care with an older patient and then participated in an interview about their experience of using the tool. All data were thematically analysed.

FINDINGS

Healthcare practitioners reported their perceptions that the TRANSITION tool was feasible and acceptable, and that they perceived the tool supported them to know what to ask and to find out information regarding their patient's transitional care needs. Some ward-based nurses reported their perception that transitional care was not their role.

CONCLUSIONS

Findings emphasise transitional care as a continuing care process that requires effective communication between nurses and older patients in acute medical wards.

RELEVANCE TO CLINICAL PRACTICE

Given shorter lengths of stay, complex care needs and slow recovery, ward-based nurses are vital in communicating with older patients about their transitional care needs. The TRANSITION tool may support communication between ward-based nurses and older patients to improve assessment and planning. Implementation of the tool will require a planned strategy to facilitate translation of the tool into routine practice of ward-based nurses to support their roles during older patients' care transitions.

Transitional care from hospital to home for older people: implementation of best practices

ABSTRACT Objective: to assess the conformity of nursing care concerning best evidence in transitional care from hospital to home for older people. Methods: a project to implement best evidence based on the model proposed by the Joanna Briggs Institute in surgical clinic of a university hospital with older people, caregivers or family members, and nurses, between July and August 2019. Eight evidence-based criteria have been audited through interviews, medical records and computerized system, presented in percentages. Results: the highest non-compliance rate found in a baseline audit was absence of continued training on transitional care and hospital discharge plan. Identifying barriers to best practices included educational programs; afterwards, there was an improvement in compliance rates in all the criteria assessed. Final considerations: the criteria based on audited evidence showed an increase in compliance rates with the strategies implemented, contributing to improving transitional care for older people.

Scoping review protocol: effectiveness of individualised nutritional care plans to reduce malnutrition during hospitalisation and up to 3 months after discharge

INTRODUCTION

More than 20% of patients are malnourished after hospitalisation. Malnutrition may negatively impact patients' outcomes as it increases the risk of complications, morbidity, mortality and loss of function. However, hospital-initiated transitional care can improve some outcomes in hospitalised adult patients. The objective of this scoping review is to map the literature that assesses the effectiveness of individualised nutritional care plans to reduce malnutrition during hospitalisation and for the first 3 months after discharge.

METHODS AND ANALYSIS

This protocol is based on the framework outlined by Arksey and O'Malley. The search strategy was developed by a medical librarian. We will search for relevant literature from the following databases: MEDLINE via PubMed, Cumulative Index to Nursing and Allied Health Literature, and Embase. We will also search the reference lists of included studies. Two independent reviewers will screen abstracts and full articles in parallel, from the included studies using specific inclusion and exclusion criteria. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols checklist facilitated the preparation of this research protocol. The scoping review will provide a narrative account of the findings from the existing literature through thematic content analysis of the extracted literature.

ETHICS AND DISSEMINATION

Since all data will be obtained from publicly available materials, research ethics approval is not required for this scoping review. The research findings will be submitted for publication in a relevant open-access peer-reviewed journal and presented at relevant conferences.