Elucidating the information exchange during interfacility care transitions: Insights from a Qualitative Study

Young carers' perspectives on navigating the healthcare system and co-designing support for their caring roles: a mixed-methods qualitative study

OBJECTIVES

Despite young carers (YCs) providing regular and significant care that exceeds what would normally be associated with an adult caregiver, we need to learn more about their experience interacting with the healthcare system. The primary study aims were to (1) describe YC experiences in interacting with the healthcare system and (2) identify types of support YC recognise as potentially helpful to their caring role.

DESIGN AND SETTING

A mixed-methods qualitative study was conducted between March 2022 and August 2022, comprising two phases of (1) semi-structured interviews and focus groups with YCs living in the community to confirm and expand earlier research findings, and (2) a co-design workshop informed by a generative research approach. We used findings from the interviews and focus groups to inform the brainstorming process for identifying potential solutions.

RESULTS

Eight YCs completed either a focus group or an interview, and four continued the study and participated in the co-design activity with 12 participants. Phase 1 resulted in three overarching themes: (1) navigating the YC role within the healthcare system; (2) being kept out of the loop; and (3) normalising the transition into caregiving. Phase 2 identified two categories: (1) YC-focused supports and (2) raising awareness and building capacity in the healthcare system.

CONCLUSION

Study findings revealed the critical role that YCs play when supporting their families during pivotal interactions in the healthcare system. Like their older caregiver counterparts, YCs struggle to navigate, coordinate and advocate for their family members while juggling their needs as they transition from adolescence to adulthood. This study provides important preliminary insights into YCs encountering professionals, which can be used to design and implement national support structures.

Stakeholder involvement in care transition planning for older adults and the factors guiding their decision-making: a scoping review

OBJECTIVE

To synthesise the existing literature on care transition planning from the perspectives of older adults, caregivers and health professionals and to identify the factors that may influence these stakeholders' transition decision-making processes.

DESIGN

A scoping review guided by Arksey and O'Malley's six-step framework. A comprehensive search strategy was conducted on 7 January 2021 to identify articles in five databases (MEDLINE, Embase, CINAHL Plus, PsycINFO and AgeLine). Records were included when they described care transition planning in an institutional setting from the perspectives of the care triad (older adults, caregivers and health professionals). No date or study design restrictions were imposed.

SETTING

This review explored care transitions involving older adults from an institutional care setting to any other institutional or non-institutional care setting. Institutional care settings include communal facilities where individuals dwell for short or extended periods of time and have access to healthcare services.

PARTICIPANTS

Older adults (aged 65 or older), caregivers and health professionals.

RESULTS

39 records were included. Stakeholder involvement in transition planning varied across the studies. Transition decisions were largely made by health professionals, with limited or unclear involvement from older adults and caregivers. Seven factors appeared to guide transition planning across the stakeholder groups: (a) institutional priorities and requirements; (b) resources; (c) knowledge; (d) risk; (e) group structure and dynamic; (f) health and support needs; and (g) personality preferences and beliefs. Factors were described at microlevels, mesolevels and macrolevels.

CONCLUSIONS

This review explored stakeholder involvement in transition planning and identified seven factors that appear to influence transition decision-making. These factors may be useful in advancing the delivery of person and family-centred care by determining how individual-level, group-level and system-level values guide decision-making. Further research is needed to understand how various stakeholder groups balance these factors during transition planning in different health contexts.

The care offered by nurses to elders with coronary artery disease from the perspective of Transitions Theory

OBJECTIVE

To analyze the planning and implementation of the care offered by nurses to elders with coronary disease during the hospital-house transition.

METHODS

Qualitative research that used the Transitions Theory as a theoretical reference. The participants were 12 nurses who work in a hospital that specializes in cardiology, in the city of Salvador-BA. A semistructured interview was carried out from January to February 2018, and the data was analyzed using the Content Analysis technique.

RESULTS

Transition care takes place on the day of discharge. The presence of the family was found to be a facilitator; low adherence, poor financial situations, the low educational levels inhibited its implementation. The rehospitalization is an indicator of the results of the transition of care.

FINAL CONSIDERATIONS

The planning and implementation of transition care is not effective. It must provide safety in the management of self-care in the home of elders with coronary disease and their families.

Development of an informational support questionnaire of transitional care for aged patients with chronic disease

OBJECTIVES

We developed an informational support questionnaire of transitional care (ISQTC) for aged patients with chronic disease and investigated its reliability and validity.

SETTING

This study was conducted in three large general hospitals in Nantong, Jiangsu Province, China.

PARTICIPANTS

A total of 130 aged patients with chronic diseases, admitted into outpatient and inpatient departments from three hospitals in China, participated in the study. The inclusion criteria were: (1) patients must provide consent to participate; (2) being 60 years and above; (3) being diagnosed with at least one chronic disease and hospitalised more than two times within the last 1 year; (4) being able to listen, speak, read and write. The exclusion criteria were: (1) refusing to participate; (2) language expression and communication barriers (and having no caregiver to assist in participation); (3) being in intensive care or long-term hospitalisation.

PRIMARY AND SECONDARY OUTCOME MEASURES

The developed questionnaire was validated and tested for reliability. The content validity of the questionnaire was determined through experts' interviews and Delphi expert consultation, and the structure validity of the questionnaire was determined by performing exploratory factor analysis. The coefficient of reliability of the questionnaire was measured using Cronbach's alpha.

RESULTS

Through Delphi expert consultation and exploratory factor analysis, the questionnaire was reduced from four dimensions and 12 items to three dimensions and 11 items. A total of 130 patients responded to the questionnaire. The alpha coefficient was 0.747.

CONCLUSION

The ISQTC is a reliable and valid instrument for evaluating aged patients with chronic disease in transitional care.

TRIAL REGISTRATION DETAILS

ChiCTR1900020923. The trial was registered on 22 January 2019.

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.

Delivering exceptionally safe transitions of care to older people: a qualitative study of multidisciplinary staff perspectives

BACKGROUND

Transitions of care are often risky, particularly for older people, and shorter hospital stays mean that patients can go home with ongoing care needs. Most previous research has focused on fundamental system flaws, however, care generally goes right far more often than it goes wrong. We explored staff perceptions of how high performing general practice and hospital specialty teams deliver safe transitional care to older people as they transition from hospital to home.

METHODS

We conducted a qualitative study in six general practices and four hospital specialties that demonstrated exceptionally low or reducing readmission rates over time. Data were also collected across four community teams that worked into or with these high-performing teams. In total, 157 multidisciplinary staff participated in semi-structured focus groups or interviews and 9 meetings relating to discharge were observed. A pen portrait approach was used to explore how teams across a variety of different contexts support successful transitions and overcome challenges faced in their daily roles.

RESULTS

Across healthcare contexts, staff perceived three key themes to facilitate safe transitions of care: knowing the patient, knowing each other, and bridging gaps in the system. Transitions appeared to be safest when all three themes were in place. However, staff faced various challenges in doing these three things particularly when crossing boundaries between settings. Due to pressures and constraints, staff generally felt they were only able to attempt to overcome these challenges when delivering care to patients with particularly complex transitional care needs.

CONCLUSIONS

It is hypothesised that exceptionally safe transitions of care may be delivered to patients who have particularly complex health and/or social care needs. In these situations, staff attempt to know the patient, they exploit existing relationships across care settings, and act to bridge gaps in the system. Systematically reinforcing such enablers may improve the delivery of safe transitional care to a wider range of patients.

TRIAL REGISTRATION

The study was registered on the UK Clinical Research Network Study Portfolio (references 35272 and 36174 ).

A systematic review of older patients' experiences and perceptions of communication about managing medication across transitions of care

BACKGROUND

Communication about managing medications may be difficult when older people move across transitions of care. Communication breakdowns may result in medication discrepancies or incidents.

OBJECTIVE

The aim of this systematic review was to explore older patients' experiences and perceptions of communication about managing medications across transitions of care.

DESIGN

A systematic review.

METHODS

A comprehensive review was conducted of qualitative, quantitative and mixed method studies using CINAHL Complete, MEDLINE, Embase and PsycINFO, Web of Science, INFORMIT and Scopus. These databases were searched from inception to 14.12.2018. Key article cross-checking and hand searching of reference lists of included papers were also undertaken.

INCLUSION CRITERIA

studies of the medication management perspectives of people aged 65 or older who transferred between care settings. These settings comprised patients' homes, residential aged care and acute and subacute care. Only English language studies were included. Comments, case reports, systematic reviews, letters, editorials were excluded. Thematic analysis was undertaken by synthesising qualitative data, whereas quantitative data were summarised descriptively. Methodological quality was assessed with the Mixed Methods Appraisal Tool.

RESULTS

The final review comprised 33 studies: 12 qualitative, 17 quantitative and 4 mixed methods studies. Twenty studies addressed the link between communication and medication discrepancies; ten studies identified facilitators of self-care through older patient engagement; 18 studies included older patients' experiences with health professionals about their medication regimen; and, 13 studies included strategies for communication about medications with older patients. Poor communication between primary and secondary care settings was reported as a reason for medication discrepancy before discharge. Older patients expected ongoing and tailored communication with providers and timely, accurate and written information about their medications before discharge or available for the post-discharge period.

CONCLUSIONS

Communication about medications was often found to be ineffective. Most emphasis was placed on older patients' perspectives at discharge and in the post-discharge period. There was little exploration of older patients' views of communication about medication management on admission, during hospitalisation, or transfer between settings.

Patient and caregiver experience in the transition from hospital to home - brainstorming results from group concept mapping: a patient-oriented study

BACKGROUND

Improving the quality of care for patients who return home after a hospital stay is an international priority; however, few jurisdictions have engaged broadly with patients and caregivers to understand what most affects their experience transitioning home. We performed Ontario-wide group concept mapping, beginning with a brainstorming phase, to understand patient and caregiver priorities in the transition.

METHODS

We used group concept mapping to engage patients and caregivers who had lived experience transitioning from hospital to home in Ontario in the previous 3 years. We report on the first phase, brainstorming, conducted over 10 weeks beginning Jan. 11, 2018 via an online survey or facilitated group discussion. Participants responded to a single focal prompt: "When leaving the hospital for home, some thing(s) that affected the experience were: ____." The study team identified recurrent concepts and overarching themes. Patients and caregivers informed the study design, recruitment and data interpretation.

RESULTS

In all, 665 people (263 patients [39.5%], 352 caregivers [52.9%] and 50 people who were both patient and caregiver [7.5%]) participated in brainstorming online, and 71 people participated in 1 of 8 group discussions. Participants identified 6 key areas affecting their experience of transition from hospital to home: home and community care, the discharge process, medical follow-up after discharge, medications, patient and caregiver education, and the kindness and caring of the health care team in hospital. Most notable were challenges with the timeliness, sufficiency, reliability and consistency of publicly funded home care services.

INTERPRETATION

Patients and caregivers from across Ontario noted a range of issues affecting their experience transitioning from hospital to home, particularly the quality and sufficiency of publicly funded home care. Our findings will be used to inform a provincial quality standard on the transition from hospital to home.

How older people enact care involvement during transition from hospital to home: A systematic review and model

Background

Current models of patient‐enacted involvement do not capture the nuanced dynamic and interactional nature of involvement in care. This is important for the development of flexible interventions that can support patients to ‘reach‐in’ to complex health‐care systems.

Objective

To develop a dynamic and interactional model of patient‐enacted involvement in care.

Search strategy

Electronic search strategy run in five databases and adapted to run in an Internet search engine supplemented with searching of reference lists and forward citations.

Inclusion criteria

Qualitative empirical published reports of older people's experiences of care transitions from hospital to home.

Data extraction and synthesis

Reported findings meeting our definition of involvement in care initially coded into an existing framework. Progression from deductive to inductive coding leads to the development of a new framework and thereafter a model representing changing states of involvement.

Main results

Patients and caregivers occupy and move through multiple states of involvement in response to perceived interactions with health‐care professionals as they attempt to resolve health‐ and well‐being‐related goals. ‘Non‐involvement’, ‘information‐acting’, ‘challenging and chasing’ and ‘autonomous‐acting’ were the main states of involvement. Feeling uninvolved as a consequence of perceived exclusion leads patients to act autonomously, creating the potential to cause harm.

Discussion and conclusion

The model suggests that involvement is highly challenging for older people during care transitions. Going forward, interventions which seek to support patient involvement should attempt to address the dynamic states of involvement and their mediating factors.