Patient and caregiver priorities in the transition from hospital to home: results from province-wide group concept mapping

"It's a stressful, trying time for the caretaker": an interpretive description qualitative study of postoperative transitions in care for older adults with frailty from the perspectives of informal caregivers

BACKGROUND

Older adults with frailty have surgery at a high rate. Informal caregivers often support the postoperative transition in care. Despite the growing need for family and caregiver support for this population, little is known about the experience of providing informal care to older adults with frailty during the postoperative transition in care. The purpose of this study was to explore what is important during a postoperative transition in care for older adults with frailty from the perspective of informal caregivers.

METHODS

This was a qualitative study using an interpretive description methodology. Seven informal caregivers to older adults [aged ≥ 65 years with frailty (Clinical Frailty Scale score ≥ 4) who had an inpatient elective surgery] participated in a telephone-based, semi-structured interview. Audio files were transcribed and analyzed using reflexive thematic analysis.

RESULTS

Four themes were constructed: (1) being informed about what to expect after surgery; (2) accessible communication with care providers; (3) homecare resources are needed for the patient; and (4) a support network for the caregivers. Theme 4 included two sub-themes: (a) respite and emotional support and (b) occupational support.

CONCLUSIONS

Transitions in care present challenges for informal caregivers of older adults with frailty, who play an important role in successful transitions. Future postoperative transitional care programs should consider making targeted information, accessible communication, and support networks available for caregivers as part of facilitating successful transitions in care.

Barriers and Facilitators of a Community-Based, Slow-Stream Rehabilitation, Hospital-to-Home Transition Program for Older Adults: Perspectives of a Multidisciplinary Care Team

The purpose of this study was to examine the perspectives of support staff, health care professionals, and care coordinators working in or referring to a community-based, slow-stream rehabilitation, hospital-to-home transition program regarding gaps in services, and barriers and facilitators related to implementation and functioning of the program. This was a qualitative descriptive study. Recruitment was conducted through purposive sampling, and 23 individuals participated in a focus groups or individual semi-structured interview. Transcripts were analyzed by six researchers using inductive thematic analysis. Themes that emerged were organized based on a socio-ecological framework. Themes were categorized as: (1) macro level, meaning gaps while waiting for program, limited program capacity, and gaps in service post-program completion; (2) meso level, meaning lack of knowledge and awareness of the program, lack of specific referral process and procedures, lack of specific eligibility criteria, and need for enhanced communication among care settings; or (3) micro level, meaning services provided, program participant benefits, person-centred communication, program structure constraints, need for use of outcome measures, and follow-up or lack of follow-up. Implementation of seamless patient information sharing, documentation, use of specific referral criteria, and use of standardized outcome measures may reduce the number of unsuitable referrals and provide useful information for referral and program staff.

"I can't imagine having to do it on your own": a qualitative study on postoperative transitions in care from the perspectives of older adults with frailty

BACKGROUND

Adults aged 65 and older have surgery more often than younger people and often live with frailty. The postoperative transition in care from hospital to home after surgey is a challenging time for older adults with frailty as they often experience negative outcomes. Improving postoperative transitions in care for older adults with frailty is a priority. However, little knowledge from the perspective of older adults with frailty is available to support meaningful improvements in postoperative transitions in care.

OBJECTIVE

To explore what is important to older adults with frailty during a postoperative transition in care.

METHODS

This qualitative study used an interpretive description methodology. Twelve adults aged ≥ 65 years with frailty (Clinical Frailty Scale score ≥ 4) who had an inpatient elective surgery and could speak in English participated in a telephone-based, semi-structured interview. Audio files were transcribed and analyzed using thematic analysis.

RESULTS

Five themes were constructed: 1) valuing going home after surgery; 2) feeling empowered through knowledge and resources; 3) focusing on medical and functional recovery; 4) informal caregivers and family members play multiple integral roles; and 5) feeling supported by healthcare providers through continuity of care. Each theme had 3 sub-themes.

CONCLUSION

Future programs should focus on supporting patients to return home by empowering patients with resources and clear communication, ensuring continuity of care, creating access to homecare and virtual support, focusing on functional and medical recovery, and recognizing the invaluable role of informal caregivers.

"I Had Bills to Pay": a Mixed-Methods Study on the Role of Income on Care Transitions in a Public-Payer Healthcare System

BACKGROUND

Income disparities may affect patients' care transition home. Evidence among patients who have access to publicly funded healthcare coverage remains limited.

OBJECTIVE

To evaluate the association between low income and post-discharge health outcomes and explore patient and caregiver perspectives on the role of income disparities.

DESIGN

Mixed-methods secondary analysis conducted among participants in a double-blind randomized controlled trial.

PARTICIPANTS

Participants from a multicenter study in Ontario, Canada, were classified as low income if annual self-reported salary was below $29,000 CAD, or between $30,000 and $50,000 CAD and supported ≥ 3 individuals.

MAIN MEASURES

The associations between low income and the following self-reported outcomes were evaluated using multivariable logistic regression: patient experience, adherence to medications, diet, activity and follow-up, and the aggregate of emergency department (ED) visits, readmission, or death up to 3 months post-discharge. A deductive direct content analysis of patient and caregivers on the role of income-related disparities during care transitions was conducted.

KEY RESULTS

Individuals had similar odds of reporting high patient experience and adherence to instructions regardless of reported income. Compared to higher income individuals, low-income individuals also had similar odds of ED visits, readmissions, and death within 3 months post-discharge. Low-income individuals were more likely than high-income individuals to report understanding their medications completely (OR 1.9, 95% CI: 1.0-3.4) in fully adjusted regression models. Two themes emerged from 25 interviews which (1) highlight constraints of publicly funded services and costs incurred to patients or their caregivers along with (2) the various ways patients adapt through caregiver support, private services, or prioritizing finances over health.

CONCLUSIONS

There were few quantitative differences in patient experience, adherence, ED visits, readmissions, and death post-discharge between individuals reporting low versus higher income. Several hidden costs for transportation, medications, and home care were reported however and warrant further research.

Raising the bar for patient experience during care transitions in Canada: A repeated cross-sectional survey evaluating a patient-oriented discharge summary at Ontario hospitals

BACKGROUND

Patient experience when transitioning home from hospital is an important quality metric linked to improved patient outcomes. We evaluated the impact of a hospital-based care transition intervention, patient-oriented discharge summary (PODS), on patient experience across Ontario acute care hospitals.

METHODS

We used a repeated cross-sectional study design to compare yearly positive (top-box) responses to four questions centered on discharge communication from the Canadian Patient Experience Survey (2016-2020) among three hospital cohorts with various levels of PODS implementation. Generalized Estimating Equations using a binomial likelihood accounting for site level clustering was used to assess continuous linear time trends among cohorts and cohort differences during the post-implementation period. This research had oversight from a public advisory group of patient and caregiver partners from across the province.

RESULTS

512,288 individual responses were included. Compared to non-implementation hospitals, hospitals with full implementation (>50% discharges) reported higher odds for having discussed the help needed when leaving hospital (OR = 1.18, 95% CI = 1.02-1.37) and having received information in writing about what symptoms to look out for (OR = 1.44, 95% = 1.17-1.78) post-implementation. The linear time trend was also significant when comparing hospitals with full versus no implementation for having received information in writing about what symptoms to look out for (OR = 1.05, 95% CI = 1.01-1.09).

INTERPRETATION

PODS implementation was associated with higher odds of positive patient experience, particularly for questions focused on discharge planning. Further efforts should center on discharge management, specifically: understanding of medications and what to do if worried once home.

Towards defining quality in home care for persons living with dementia

INTRODUCTION

Accelerating rates of dementia worldwide coupled with older adults living longer in the community calls for greater focus on quality home care support services. Few frameworks for quality dementia home care exist though prior findings have found elements considered to be important for "good" home care for people living with dementia. This study aimed to identify core components of a quality home care experience for people with dementia and their caregivers.

METHODS

As part of a larger research study, in-depth interviews were conducted with persons living with dementia and caregivers (n = 25) to explore hospital-to-home care transitions. The design used for this study was a qualitative description. We used deductive-inductive thematic analysis, which was informed by previous work in this area. Open codes were mapped to pre-determined themes, and for codes not accommodated by an a piori framework, new themes were developed.

FINDINGS

Our findings resulted in 4 overarching themes. Two themes were identified deductively (Availability and Acceptability of Home Care Services) and two inductively (Adaptability and Affordability of Home Care Services). Findings highlight the roles of family-care provider partnerships and responsive support in receiving quality home care, and the cost associated with unmet needs.

INTERPRETATION

With an aging population, an increase in home care client acuity, and post-COVID-19 concerns over long-term care, more attention is needed to improve the quality of home care. The demand for these services will continue to increase particularly for those living with dementia and their families. The findings of availability, acceptability, adaptability, and affordability as core to quality care can help lay the groundwork for a home care framework for persons living with dementia and their caregivers. Future research could benefit from comparative analyses to evaluate the applicability of the findings to non-dementia home care service users and caregivers.

Evaluations of postoperative transitions in care for older adults: a scoping review

Background

Most people having major surgery are over the age of 65. The transition out of hospital is a vulnerable time for older adults, particularly after major surgery. Research on postoperative transitions in care is growing, but it is not clear how postoperative transitions are being evaluated. The objective of this scoping review was to synthesize processes and outcomes used to evaluate postoperative transitions in care for older adults.

Methods

We conducted a scoping review that included articles evaluating a postoperative transition in care among adults aged > 65 having major elective surgery. We searched Medline (Ovid), EMBASE (Ovid), CINHAL, and Cochrane Central Register of Controlled Trials (CENTRAL) from their respective inception dates to April 6, 2021. We also searched The World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov from their respective inception dates to April 6, 2021. Screening and data extraction was completed by reviewers in duplicate. Data relevant to study design and objective, intervention description, and process or outcome evaluations were extracted. Process evaluations were categorized using the Ideal Transitions in Care Framework, and outcome evaluations were categorized using the Institute for Healthcare Improvement Triple Aim Framework.

Results

After screening titles and abstracts and full-text article review, we included 20 articles in our final synthesis. There was variability in the processes and outcomes used to evaluate postoperative transitions in care. The most common outcomes evaluated were health service utilization (n = 9), including readmission and Emergency Department visits, experiential outcomes (n = 9) and quality of life (n = 7). Process evaluations included evaluating the education provided to patients to promote self-management (n = 6), coordination of care among team members (n = 3) and outpatient follow-up (n = 3). Only two articles measured frailty, one article used theory to guide their evaluations and no articles engaged knowledge users.

Conclusions

There is inconsistency in how postoperative transitions in care were evaluated. There is a need to use theories and to engage key stakeholders involved in postoperative transitions in care, including older adults and their caregivers, to identify the most appropriate approaches for developing and evaluating interventions to meaningfully improve care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02989-6.

Implementation of Hospital-to-Home Model for Nutritional Nursing Management of Patients with Chronic Kidney Disease Using Artificial Intelligence Algorithm Combined with CT Internet

The objective of this study was to evaluate the application value of “Internet + hospital-to-home (H2H)” nutritional care model using the improved wavelet transform algorithm based on computed tomography (CT) images in the nutritional care management of chronic kidney disease (CKD) stages 3-5. A total of 120 patients with CKD were the research objects and they were randomly divided into two groups. The normal nutritional nursing model was used for nursing of patients in the control group, and the “Internet + H2H″ model was used for the observation group (H2H group), with 60 cases in each group. The nursing effect was evaluated using 320-slice volume CT low-dose perfusion imaging images, anthropometry, laboratory biochemical tests, and other survey scores. The results showed that compared with the mean filter denoising (MFD) algorithm and the orthogonal wavelet denoising (OWD) algorithm, the mean square error (MSE) and signal noise ratio (SNR) values of the IWT algorithm were better (40.0781 vs 45.2891, 59.2123)/(20.0122 vs 18.2311, 15.7812) (P < 0.05). The arm muscle circumference (MAC) (239.77 ± 18.24 vs 243.94 ± 18.72 mm) and triceps skindold (TSF) value (8.87 ± 2.74 vs 10.04 ± 2.90 mm) of the patients in the H2H group were greatly improved after the nursing (P < 0.05). For biochemical indicators, serum albumin (ALB) (35.22 ± 4.98 vs 45.32 ± 4.21) g/L, prealbumin (PAB) (289.94 ± 72.99 vs 341.79 ± 74.45) mg/L, hemoglobin (Hb) (97.62 ± 24.87 vs 110.65 ± 28.83) g/L, and blood urea nitrogen (BUN) (15.74 ± 9.87 vs 11.06 ± 5.69) mmol/L of patients in H2H group were improved (P < 0.05). After nursing, the nutritional screening score of the H2H group was obviously improved (83.33% (before) vs 50% (after)), the total score of health quality assessment (114.89 ± 5.23) in the H2H group was much higher than that of the control group (87.22 ± 14.89), and the satisfaction on the nursing model was higher in the H2H group (100% vs 71.67%) (P < 0.05). The renal cortex BF before and after nursing was significantly different between the two groups of patients (P < 0.05), and the BE of the H2H group was significantly higher than that of the control group after treatment ((335.12 ± 52.74) mL·100 g⁻¹·min⁻¹ vs (289.90 ± 53.91) mL·100 g⁻¹·min⁻¹) (P < 0.05). In summary, the “Internet + H2H″ nutritional nursing model was more individualized, which can better improve the physical quality of patients with stages 3-5 of CKD, improve the psychological state of patients, and further enhance the prognosis of the disease. In addition, the IWT algorithm showed better effects in the processing of the image of 320-slice volume CT low-dose perfusion imaging, and it was worthy of clinical application.

Legal, geographic and organizational contexts that shape knowledge sharing in the hospital discharge process for people experiencing homelessness in Toronto, Canada

People experiencing homelessness use acute healthcare at higher rates than the general population, yet hospitals frequently discharge them to the streets or emergency shelters. Available literature on the hospital discharge process for people experiencing homelessness identifies knowledge sharing as an important and challenging part of the discharge process; however, it does little to explain what generates these challenges or what might support knowledge sharing. In this study, we explain under which contexts certain mechanisms are triggered to facilitate knowledge sharing between hospitals and shelters during the discharge process. Between September 2018 and April 2019, we interviewed 33 participants: hospital workers on general medicine wards across three hospitals; shelter workers; researchers, policy advisors or advocates working at the intersection of homelessness and healthcare in Toronto. We find that within the legal context of health information protection, the concept of "circle of care" has created barriers to knowledge sharing between hospitals and shelters by excluding shelter workers from discharge planning. We note, however, that the degree to which hospital workers have navigated these barriers and brought shelter workers into the discharge process varies across hospitals. We explore this variation and find that certain geographic and organisational contexts have activated the development of institutional- and individual-level relationships between hospitals and shelters or their workers, respectively. We suggest that these relationships generate increased trust and communication and have led to knowledge sharing between hospitals and shelters. These findings are applicable in most urban centres with hospitals and where people experiencing homelessness live. Understanding the role of context is imperative for developing appropriate and effective interventions to improve hospital discharge processes. The development and implementation of more effective discharge processes can contribute to improved post-discharge care and recovery for this patient population and contribute to addressing health equity.

Hospital to Home: Supporting the Transition From Hospital to Home for Older Adults

Background

An increasing proportion of older adults experience avoidable hospitalizations, and some are potentially entering long-term care homes earlier and often unnecessarily. Older adults often lack adequate support to transition from hospital to home, without access to appropriate health services when they are needed in the community and resources to live safely at home.

Purpose

This study collaborated with an existing enhanced home care program called Home Again in Nova Scotia, to identify factors that contribute to older adult patients being assessed as requiring long-term care when they could potentially return home with enhanced supports.

Methods

Using a case study design, this study examined in-depth experiences of multiple stakeholders, from December 2019 to February 2020, through analysis of nine interviews for three focal patient cases including older adult patients, their family or friend caregivers, and healthcare professionals.

Results

Findings indicate home care services for older adults are being sought too late, after hospital readmission, or a rapid decline in health status when family caregivers are already experiencing caregiver burnout. Limitations in home care services led to barriers preventing family caregivers from continuing to care for older adults at home.

Conclusions

This study contributes knowledge about gaps within home care and transitional care services, highlighting the importance of investing in additional home care services for rehabilitation and prevention of rapidly deteriorating health.

Effectiveness of a nurse-led hospital-to-home transitional care intervention for older adults with multimorbidity and depressive symptoms: A pragmatic randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of a nurse-led hospital-to-home transitional care intervention versus usual care on mental functioning (primary outcome), physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health service use costs in older adults with multimorbidity (≥ 2 comorbidities) and depressive symptoms.

DESIGN AND SETTING

Pragmatic multi-site randomized controlled trial conducted in three communities in Ontario, Canada. Participants were allocated into two groups of intervention and usual care (control).

PARTICIPANTS

127 older adults (≥ 65 years) discharged from hospital to the community with multimorbidity and depressive symptoms.

INTERVENTION

This evidence-based, patient-centred intervention consisted of individually tailored care delivery by a Registered Nurse comprising in-home visits, telephone follow-up and system navigation support over 6-months.

OUTCOME MEASURES

The primary outcome was the change in mental functioning, from baseline to 6-months. Secondary outcomes were the change in physical functioning, depressive symptoms, anxiety, perceived social support, patient experience, and health service use cost, from baseline to 6-months. Intention-to-treat analysis was performed using ANCOVA modeling.

RESULTS

Of 127 enrolled participants (63-intervention, 64-control), 85% had six or more chronic conditions. 28 participants were lost to follow-up, leaving 99 (47 -intervention, 52-control) participants for the complete case analysis. No significant group differences were seen for the baseline to six-month change in mental functioning or other secondary outcomes. Older adults in the intervention group reported receiving more information about health and social services (p = 0.03) compared with the usual care group.

CONCLUSIONS

Although no significant group differences were seen for the primary or secondary outcomes, the intervention resulted in improvements in one aspect of patient experience (information about health and social services). The study sample fell below the target sample (enrolled 127, targeted 216), which can account for the non-significant findings. Further research on the impact of the intervention and factors that contribute to the results is recommended.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03157999.

Implementation, spread and impact of the Patient Oriented Discharge Summary (PODS) across Ontario hospitals: a mixed methods evaluation

Background

Traditional discharge processes lack a patient-centred focus. This project studied the implementation and effectiveness of an individualized discharge tool across Ontario hospitals. The Patient Oriented Discharge Summary (PODS) is an individualized discharge tool with guidelines that was co-designed with patients and families to enable a patient-centred process.

Methods

Twenty one acute-care and rehabilitation hospitals in Ontario, Canada engaged in a community of practice and worked over a period of 18 months to implement PODS. An effectiveness-implementation hybrid design using a triangulation approach was used with hospital-collected data, patient and provider surveys, and interviews of project teams. Key outcomes included: penetration and fidelity of the intervention, change in patient-centred processes, patient and provider satisfaction and experience, and healthcare utilization. Statistical methods included linear mixed effects models and generalized estimating equations.

Results

Of 65,221 discharges across hospitals, 41,884 patients (64%) received a PODS. There was variation in reach and implementation pattern between sites, though none of the between site covariates was significantly associated with implementation success. Both high participation in the community of practice and high fidelity were associated with higher penetration. PODS improved family involvement during discharge teaching (7% increase, p = 0.026), use of teach-back (11% increase, p < 0.001) and discussion of help needed (6% increase, p = 0.041). Although unscheduled healthcare utilization decreased with PODS implementation, it was not statistically significant.

Conclusions

This project highlighted the system-wide adaptability and ease of implementing PODS across multiple patient groups and hospital settings. PODS demonstrated an improvement in patient-centred discharge processes linked to quality standards and health outcomes. A community of practice and high quality content may be needed for successful implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06374-8.

'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.

Hospital Discharge Planning for People Experiencing Homelessness Leaving Acute Care: A Neglected Issue

People experiencing homelessness have worse health outcomes than the general population and limited access to primary/preventative healthcare. This leads to high hospital readmission rates. Effective discharge planning can improve recovery rates and reduce hospital costs. However, most hospital discharge policies and best practice guidelines are not tailored to patients with no fixed address, contributing to inappropriate discharges and health inequities for people experiencing homelessness. We discuss the lack of discharge policies, identifiable processes or plans specifically tailored to this population as a healthcare and policy gap, and we identify key areas for better understanding and addressing this issue.