Care transition experiences of spousal caregivers: from a geriatric rehabilitation unit to home

The meaning of preparedness for informal caregivers of older adults: A concept analysis

AIM

To examine the concept of preparedness over time in research with informal caregivers of older adults.

DESIGN

Concept analysis.

METHODS

Rodgers' evolutionary method of concept analysis was used to guide this theoretical paper due to the dynamic nature of preparedness, which is influenced by both context and time. Using Rodgers' inductive approach, concept elements were derived from a content analysis of included studies. In the final step, to generate hypotheses and implications regarding the concept, the conceptual structure of preparedness of informal caregivers of older adults was connected to a theoretical problem in the nursing discipline using the Caregiving Stress Process Framework.

DATA SOURCES

Four databases (EBSCO CINAHL, Ovid MEDLINE, Ovid PsycINFO and Scopus) were searched in November 2022 and updated in September 2023. No date limits were set for searching, as the intent was to analyse possible variations of the concept over time.

RESULTS

The attributes of preparedness include self-confidence, having knowledge, skills and abilities to perform daily tasks, handling emotions and developed over time. These attributes can be compared with the stressors outlined in the Caregiving Stress Process Framework (i.e., the moment the caregiver identifies some 'stressor'; something that prevents them from feeling confident in their preparedness).

CONCLUSION

The concept of preparedness of informal caregivers of older adults is defined as caregiver's self-confidence about their current competence related to the knowledge, skills and abilities to perform daily tasks, and to handle emotions over time. To link the concept to a theoretical perspective, we propose adaptations to a well-known theory, the Caregiving Stress Process Framework. Future research on caregiving preparedness needs to avoid circular definitions and work with the attributes of preparedness to support caregivers.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

This paper contributes to the development of interventions that focus on the health and preparedness of informal caregivers of older adults. Clarifying the concept of preparedness helps nurses to support caregivers since it is then known which aspects are included in the preparedness of caregivers (e.g., daily tasks and handling emotions). A more fulsome understanding of preparedness supports us to see beyond stressors of caregiving.

IMPACT

This study addresses informal caregivers of older adults' preparedness to provide care. We synthesized existing definitions that have been used in research with this population to propose a robust conceptualization of the concept of preparedness, which contributes to better understanding of how preparedness can be supported.

REPORTING METHOD

We were unable to locate a reporting method related to this kind of work (concept analysis).

PATIENT OR PUBLIC CONTRIBUTION

Not applicable as no new data generated.

Roles and experiences of informal caregivers of older adults in community and healthcare system navigation: a scoping review

OBJECTIVE

Informal caregivers are playing a vital role in improving the degree to which older adults access community and healthcare systems in a more seamless and timely manner, thereby fulfilling their complex needs. It is critical to understand their experiences and perspectives while navigating these systems. This review aimed to identify and organise the research findings on the roles and experiences of informal caregivers of older adults while navigating community and healthcare systems.

DESIGN

This scoping review was undertaken according to the Joanna Briggs Institute's Reviewer manual. Four databases were used: AgeLine, PsycINFO, CINAHL and Medline to capture literature with a focus on informal caregivers whose care recipients are aged 55 years or older. Articles were included if they focused on examining the experience, perspective and/or role of informal caregivers in providing care for their older care recipients, while articles were excluded if they only focused on healthcare professionals or older adults.

RESULTS

A total of 24 studies were identified that met the study inclusion criteria. This review elucidated the roles of caregivers as a primary system navigator and as an advocate for older adults. Numerous challenges/barriers in system navigation were uncovered, such as lack of consistency in fragmented systems, as well as facilitators, including interface/coordination roles. Finally, recommendations for better system navigation such as caregiver engagement and integration of continuity of care services were identified.

CONCLUSION

The need to raise the visibility of the roles and experiences of informal caregivers in system navigation was highlighted. Further research needs to focus on implementing interventions for informal caregivers incorporating a care coordinator to fill the care gap within community and healthcare systems. This review has the potential to foster greater integration of community and healthcare systems.

Informal carer support needs, facilitators and barriers in transitional care for older adults from hospital to home: A scoping review

AIM

To synthesise evidence about informal carers' (carers) experience of their support needs, facilitators and barriers regarding transitional care of older adults with multimorbidity.

BACKGROUND

Carers provide crucial support for older adults during care transitions. Although health practitioners are well positioned to support carers, system factors including limited healthcare resources can compromise the quality of care transitions.

DESIGN

Scoping review.

METHODS

Searches were undertaken of the published literature. Five databases were searched including MEDLINE, CINAHL, EMBASE, PsycINFO and the Cochrane Library. Two reviewers independently screened articles to identify relevant studies. Studies were retrieved from January 2000 to July 2022. Data were extracted and tabulated for study characteristics, support needs, facilitators and barriers. Key themes and patterns were synthesised across the studies.

RESULTS

Eighteen studies including N = 3174 participants were retrieved. Most studies (n = 13) employed qualitative designs. Five studies used surveys. Carers reported their need to: be involved in coordinated discharge planning; advocate and be involved in decision-making; and receive community-based follow-up. Carers described facilitators and barriers in four themes: (1) relationships with the older adult and health practitioners, (2) being involved in coordinated discharge planning; (3) communication and information strategies; and (4) community-based follow-up. Synthesis of themes across all studies resulted in the identification of five areas of research: carers' health literacy; community-based care; carers' involvement in transitional care planning; inpatient and community health practitioners' communication skills; and culturally diverse carers' experiences.

CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE

The review highlights the importance of quality communication and relationships between carers, older adults, health practitioners and health organisations. Although information and education are important there is a need for further research to examine systems that support communication between carers, older adults and health practitioners and health literacy for all carers including culturally diverse carers.

The hospital-to-home care transition experience of home care clients: an exploratory study using patient journey mapping

BACKGROUND

Care transitions have a significant impact on patient health outcomes and care experience. However, there is limited research on how clients receiving care in the home care sector experience the hospital-to-home transition. An essential strategy for improving client care and experience is through client engagement efforts. The study's aim was to provide insight into the care transition experiences and perspectives of home care clients and caregivers of those receiving home care who experienced a hospital admission and returned to home care services by thematically and illustratively mapping their collective journey.

METHODS

This study applied a qualitative descriptive exploratory design using a patient journey mapping approach. Home care clients and their caregivers with a recent experience of a hospital discharge back to the community were recruited. A conventional inductive approach to analysis enabled the identification of categories and a collective patient journey map. Follow-up interviews supported the validation of the map.

RESULTS

Seven participants (five clients and two caregivers) participated in 11 interviews. Participants contributed to the production of a collective journey map and the following four categories and themes: (1) Touchpoints as interactions with the health system; Life is changing; (2) Pain points as barriers in the health system: Sensing nobody is listening and Trying to find a good fit; (3) Facilitators to positive care transitions: Developing relationships and gaining some continuity and Trying to advocate, and (4) Emotional impact: Having only so much emotional capacity.

CONCLUSIONS

The patient journey map enabled a collective illustration of the care transition depicted in touchpoints, pain points, enablers, and feelings experienced by home care recipients and their caregivers. Patient journey mapping offers an opportunity to acknowledge home care clients and their caregivers as critical to quality care delivery across the continuum.

Connect-Home transitional care from skilled nursing facilities to home: A stepped wedge, cluster randomized trial

BACKGROUND

Skilled nursing facility (SNF) patients and their caregivers who transition to home experience complications and frequently return to acute care. We tested the efficacy of the Connect-Home transitional care intervention on patient and caregiver preparedness for care at home, and other patient and caregiver-reported outcomes.

METHODS

We used a stepped wedge, cluster-randomized trial design to test the intervention against standard discharge planning (control). The setting was six SNFs and six home health offices in one agency. Participants were 327 dyads of patients discharged from SNF to home and their caregivers; 11.1% of dyads in the control condition and 81.2% in the intervention condition were enrolled after onset of COVID-19. Patients were 63.9% female and mean age was 76.5 years. Caregivers were 73.7% female and mean age was 59.5 years. The Connect-Home intervention includes tools, training, and technical assistance to deliver transitional care in SNFs and patients' homes. Primary outcomes measured at 7 days included patient and caregiver measures of preparedness for care at home, the Care Transitions Measure-15 (patient) and the Preparedness for Caregiving Scale (caregiver). Secondary outcomes measured at 30 and 60 days included the McGill Quality of Life Questionnaire, Life Space Assessment, Zarit Caregiver Burden Scale, Distress Thermometer, and self-reported number of patient days in the ED or hospital in 30 and 60 days following SNF discharge.

RESULTS

The intervention was not associated with improvement in patient or caregiver outcomes in the planned analyses. Post-hoc analyses that distinguished between pre- and post-pandemic effects suggest the intervention may be associated with increased patient preparedness for discharge and decreased number of acute care days.

CONCLUSIONS

Connect-Home transitional care did not improve outcomes in the planned statistical analysis. Post-hoc findings accounting for COVID-19 impact suggest SNF transitional care has potential to increase patient preparedness and decrease return to acute care.

Participating in the Illness Journey: Meanings of Being a Close Relative to an Older Person Recovering from Hip Fracture-A Phenomenological Hermeneutical Study

When an older person suffers an acute event, such as a hip fracture, it influences the whole family. Research shows that while close relatives want to be a part of the older person's life during recovery it is associated with a high perceived level of stress and burden. To provide in-depth knowledge of close relatives' experiences in this situation, the aim of this study was to elucidate meanings of being a close relative to an older person recovering from hip fracture surgery.This study has a qualitative descriptive phenomenological hermeneutical design. Narrative interviews were conducted with ten close relatives. Analysis was conducted using phenomenological hermeneutical interpretation which provided a deeper understanding of the close relatives' lived experiences of their older person's recovery from hip fracture surgery. The structural analysis revealed two themes; "Participating in the illness journey", which was constructed of the subthemes of facing the unimaginable yet expected, encountering healthcare personnel, and noticing recovery and "Putting oneself aside", which was constructed of the subthemes of placing daily life on hold, giving support, and feeling concern and fear.

Unique Care Needs of People with Dementia and Their Caregivers during Transitions from Skilled Nursing Facilities to Home and Assisted Living: A Qualitative Study

OBJECTIVES

The purpose of the study was to describe unique care needs of people with dementia (PWD) and their caregivers during transitions from skilled nursing facilities (SNF) to home.

DESIGN

A qualitative study using focus groups, semistructured interviews, and descriptive qualitative analysis.

SETTING AND PARTICIPANTS

The study was set in one state, in 4 SNFs where staff had experience using a standardized transitional care protocol. The sample included 22 SNF staff, 4 home health nurses, 10 older adults with dementia, and their 10 family caregivers of whom 39 participated in focus groups and/or interviews.

METHODS

Data collection included 4 focus groups with SNF staff and semistructured interviews with home health nurses, SNF staff, PWD, and their family caregivers. Standardized focus group and interview guides were used to elicit participant perceptions of transitional care. We used the framework analytic approach to qualitative analysis. A steering committee participated in interpretation of findings.

RESULTS

Participants described 4 unique care needs: (1) PWD and caregivers may not be ready to fully engage in dementia care planning while in the SNF, (2) caregivers are not prepared to manage dementia symptoms at home, (3) SNF staff have difficulty connecting PWD and caregivers to community supports, and (4) caregivers receive little support to address their own needs.

CONCLUSIONS AND IMPLICATIONS

Based on findings, recommendations are offered for adapting transitional care to address the needs of PWD and their caregivers. Further research is needed (1) to confirm these findings in larger, more diverse samples and (2) to adapt and test interventions to support successful community discharge of PWD and their caregivers.

Engagement of older adults in regional health innovation: The ECOTECH concept mapping project

Objectives:

Regional health innovation ecosystems can activate collaboration and support planning, self-management and development and commercialization of innovations. We sought to understand how older adults and their caregivers can be meaningfully engaged in regional health innovation ecosystems focused on health and aging–related technology innovation.

Methods:

A six-phase concept mapping technique gathered data over six time points across Canada. Brainstorming conducted online and in person identified engagement ideas. Statements were sorted by similarity and rated by participants on importance and feasibility. Qualitative approaches and multidimensional scaling, hierarchical cluster analysis, descriptive statistics and t tests were used for analysis.

Results:

Sixty-two unique ideas were assembled into a seven-cluster framework of priorities for engagement in regional health innovation ecosystems including public forums, co-production and partnerships, engagement, linkage and exchange, developing cultural capacity, advocacy and investment in the ecosystem.

Conclusions:

This study identified a framework of priorities for directions and strategies for older adult and caregiver engagement in regional health innovation ecosystems. Next steps include collaborations to develop regional health innovation ecosystems that actively engage older adults and their caregivers in health and aging–related technology innovation.

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.

'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.

Caregivers' Experiences Regarding Training and Support in the Post-Acute Home Health-Care Setting

Background:

Post-acute home health-care (HHC) services provide a unique opportunity to train and support family caregivers of older adults returning home after a hospitalization. To enhance family-focused training and support strategies, we must first understand caregivers’ experiences.

Objective:

To explore caregivers’ experiences regarding training and support for managing older adults’ physical functioning (PF) needs in the post-acute HHC setting.

Method:

We conducted a qualitative descriptive study using semi-structured telephone interviews of 20 family caregivers. Interviews were recorded, transcribed, and analyzed using conventional content analysis.

Results:

We identified the following primary categories: facilitators to learning (eg, past experience, learning methods), barriers to learning (eg, learning on their own, communication, timing/logistics, preferred information and timing of information delivery), and interactions with HHC providers (eg, positive/negative interactions, provider training and knowledge).

Conclusion:

Caregivers were responsive to learning strategies to manage older adults’ PF needs and, importantly, voiced ideas to improve family-focused training and support. HHC providers can use these findings to tailor training and support of family caregivers in the post-acute HHC setting.

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.

Caregivers' Perceptions Managing Functional Needs Among Older Adults Receiving Post-Acute Home Health Care

Caregivers play important roles in managing the physical functioning (PF) needs of older adults transitioning home after a hospitalization. Training and support of caregivers in the post-acute home health care (HHC) setting should incorporate caregivers' perspectives. To explore caregivers' experiences managing PF needs in the post-acute HHC setting, semi-structured telephone interviews of 20 caregivers were conducted. Conventional content analysis revealed patient-, caregiving task-, caregiver-, and home environment-related themes consistent with the Theory of Dependent Care. Caregivers highlighted the dynamics and contributors of PF needs for older patients in the post-acute HHC setting and depicted the enormity of caregiving tasks needed to manage older patients' PF needs. Caregivers also described their perceived roles and challenges in managing PF deficits, including a sense of isolation when they were the sole caregiver. Findings from this research can guide nursing efforts to target caregiver training and support during this critical care transition. [Res Gerontol Nurs. 2019; 12(4):174-183.].

Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study

BACKGROUND

Middle-aged and older adults requiring skilled home healthcare ('home health') services following hospital discharge are at high risk of experiencing suboptimal outcomes. Information management (IM) needed to organise and communicate care plans is critical to ensure safety. Little is known about IM during this transition.

OBJECTIVES

(1) Describe the current IM process (activity goals, subactivities, information required, information sources/targets and modes of communication) from home health providers' perspectives and (2) Identify IM-related process failures.

METHODS

Multisite qualitative study. We performed semistructured interviews and direct observations with 33 home health administrative staff, 46 home health providers, 60 middle-aged and older adults, and 40 informal caregivers during the preadmission process and initial home visit. Data were analysed to generate themes and information flow diagrams.

RESULTS

We identified four IM goals during the preadmission process: prepare referral document and inform agency; verify insurance; contact adult and review case to schedule visit. We identified four IM goals during the initial home visit: assess appropriateness and obtain consent; manage expectations; ensure safety and develop contingency plans. We identified IM-related process failures associated with each goal: home health providers and adults with too much information (information overload); home health providers without complete information (information underload); home health coordinators needing information from many places (information scatter); adults' and informal caregivers' mismatched expectations regarding home health services (information conflict) and home health providers encountering inaccurate information (erroneous information).

CONCLUSIONS

IM for hospital-to-home health transitions is complex, yet key for patient safety. Organisational infrastructure is needed to support IM. Future clinical workflows and health information technology should be designed to mitigate IM-related process failures to facilitate safer hospital-to-home health transitions.

Care transition types across acute, sub-acute and primary care

Purpose

The purpose of the paper is to examine the care transitions of older people who transfer between home, acute and sub-acute care to determine if there were common transition types and areas for improvements.

Design/methodology/approach

A longitudinal case study design was used to examine care transitions of 19 older people and their carers as a series of transitions and a whole-of-system experience. Case study accounts synthesising semi-structured interviews with function and service use data from medical records were compared.

Findings

Three types of care transitions were derived from the analysis: manageable, unstable and disrupted. Each type had distinguishing characteristics and older people could experience elements of all types across the system. Transition types varied according to personal and systemic factors.

Originality/value

This study identifies types of care transition experiences across acute, sub-acute and primary care from the perspective of older people and their carers. Understanding transition types and their features can assist health professionals to better target strategies within and across the system and improve patient experiences as a whole.

End-of-Life Caregiver Social Support Activation: The Roles of Hospice Clinicians and Professionals

Caregivers of those with life-limiting illness face many complicated tasks, including providing direct patient care, communicating with professionals, and managing the logistical demands of daily activities. To assist with caregiving responsibilities, caregivers require social support from social network members at all points in the illness process. This study analyzes themes from interviews with 61 caregivers of patients enrolled in hospice services to identify the types of support caregivers mobilize from new social network members for social support during the end-of-life care process. Themes indicate that caregivers receive accessible, immediate, caregiver-centered emotional support from hospice health care professionals, and situationally tailored, understandable informational support from other types of professionals. In addition, caregivers received overlapping emotional and informational support from hospice health care professionals. Findings enhance the understanding of how caregivers receive tailored emotional and informational support.

Connect-Home: Transitional Care of Skilled Nursing Facility Patients and their Caregivers

BACKGROUND

Older adults that transfer from skilled nursing facilities (SNF) to home have significant risk for poor outcomes. Transitional care of SNF patients (i.e., time-limited services to ensure coordination and continuity of care) is poorly understood.

OBJECTIVE

To determine the feasibility and relevance of the Connect-Home transitional care intervention, and to compare preparedness for discharge between comparison and intervention dyads.

DESIGN

A non-randomized, historically controlled design-enrolling dyads of SNF patients and their family caregivers.

SETTING

Three SNFs in the Southeastern United States.

PARTICIPANTS

Intervention dyads received Connect-Home; comparison dyads received usual discharge planning. Of 173 recruited dyads, 145 transferred to home, and 133 completed surveys within 3 days of discharge.

INTERVENTION

The Connect-Home intervention consisted of tools and training for existing SNF staff to deliver transitional care of patient and caregiver dyads.

MEASUREMENTS

Feasibility was assessed with a chart review. Relevance was assessed with a survey of staff experiences using the intervention. Preparedness for discharge, the primary outcome, was assessed with Care-Transitions Measure-15 (CTM-15).

RESULTS

The intervention was feasible and relevant to SNF staff (i.e., 96.9% of staff recommended intervention use in the future). Intervention dyads, compared to comparison dyads, were more prepared for discharge (CTM-15 score 74.7 vs 65.3, mean ratio 1.16, 95% CI: 1.08, 1.24).

CONCLUSION

Connect-Home is a promising transitional care intervention for older patients discharged from SNF care. The next step will be to test the intervention using a cluster randomized trial, with patient outcomes including re-hospitalization.

Patients' and Family Caregivers' Goals for Care During Transitions Out of the Hospital

The aims of this study were to (a) describe the nature of patients' goals upon discharge from hospital, family caregivers' goals for their loved ones, and family caregivers' goals for themselves; (b) determine the degree of concordance with respect to the three elicited goals; (c) ascertain goal attainment across the three elicited goals; and (d) examine factors predictive of goal attainment. Our findings support the position that eliciting patient and family caregiver goals and promoting goal attainment may represent an important step toward promoting greater patient and family caregiver engagement in their care.

The role of caregivers in interfacility care transitions: a qualitative study

A qualitative design was used to explore the nature of caregiver involvement in care transitions of patients being transferred from an acute care hospital to a rehabilitation hospital. Participants included older adults (n=13), informal caregivers (n=9), and health care professionals (n=50) from inpatient orthopedic units in two academic health science centers and one orthopedic inpatient rehabilitation unit. Semistructured interviews were conducted, audio-taped, and transcribed. Directed content analysis revealed the following four themes: watching, being an active care provider, advocating, and navigating the health care system. Participants described being actively involved in the care of their family member, yet they were not actively engaged by health care professionals to be involved in the care of their family member. There is a need to reconcile the tension between the level of involvement of caregivers in the care of family members who are patients and the level of engagement throughout the care transition. By providing relevant information and authentically engaging caregivers as equal partners in the care transition, they are better able to navigate the health care system post-transfer to the rehabilitation setting and discharge to home.

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

This meta-synthesis aimed to improve understanding of user experience of older people, carers, and health providers; and care integration in the care of older people transitioning from hospital to home. Following our systematic search, we identified and synthesized 20 studies, and constructed a comprehensive framework. We derived four themes: (1) 'Who is taking care of what? Trying to work together"; (2) 'Falling short of the mark'; (3) 'A proper discharge'; and (4) 'You adjust somehow.' The themes that emerged from the studies reflected users' experience of discharge and transitional care as a social process of 'negotiation and navigation of independence (older people/carers), or dependence (health providers).' Users engaged in negotiation and navigation through the interrogative strategies of questioning, discussion, information provision, information seeking, assessment, and translation. The derived themes reflected care integration that facilitated, or a lack of care integration that constrained, users' experiences of negotiation and navigation of independence/dependence.

Understanding informal carers' experiences of caring for older people with a hip fracture: a systematic review of qualitative studies

PURPOSE

This systematic review aimed to reconceptualize experiences from a variety of papers to provide direction for research, policy and practice.

METHOD

Meta-ethnography was used to inform the review, and 21 studies were included.

FINDINGS

The analysis identified a core theme of "engaging in care: struggling through", as carers, who wanted to be involved in caring, learnt to live with the intense and stressful impact of caring and changes to their life. The core theme is represented through three themes (1) Helping another to live, (2) Adapting ways of living and (3) Negotiating the unknown.

CONCLUSIONS

The discussion identified a focus on carers of people suffering from a hip fracture, the willingness of informal carers to engage in caring and the intense experience of adapting to changes in relationships and dependency alongside a steep experiential learning curve. Tensions exist in negotiations with complex health care systems as carers do not feel their expertise is valued and struggle to find and understand information. Implications for Rehabilitation Including relatives/carers in the umbrella of care within a family-centred approach. Involving relatives/carers within shared decision-making about care requirements and rehabilitation goals. Utilizing forms of experiential learning to help the development of relatives/carers skills in relation to their role as carer. Providing opportunities for carers to explore ways of sustaining their own health through self-compassion.

Using a complex adaptive system lens to understand family caregiving experiences navigating the stroke rehabilitation system

BACKGROUND

Family caregivers provide the stroke survivor with social support and continuity during the transition home from a rehabilitation facility. In this exploratory study we examined family caregivers' perceptions and experiences navigating the stroke rehabilitation system. The theories of continuity of care and complex adaptive systems were integrated to examine the transition from a stroke rehabilitation facility to the patient's home. This study provides an understanding of the interacting complexities at the macro and micro levels.

METHODS

A convenient sample of family caregivers (n = 14) who provide care for a stroke survivor were recruited 4-12 weeks following the patient's discharge from a stroke rehabilitation facility in Ontario, Canada. Interviews were conducted with family caregivers to examine their perceptions and experiences navigating the stroke rehabilitation system. Directed and inductive content analysis and the theory of Complex Adaptive Systems were used to interpret the perceptions of family caregivers.

RESULTS

Health system policies and procedures at the macro-level determined the types and timing of information being provided to caregivers, and impacted continuity of care and access to supports and services at the micro-level. Supports and services in the community, such as outpatient physiotherapy services, were limited or did not meet the specific needs of the stroke survivors or family caregivers.

CONCLUSION

Relationships with health providers, informational support, and continuity in case management all influence the family caregiving experience and ultimately the quality of care for the stroke survivor, during the transition home from a rehabilitation facility.

Care transitions: a systematic review of best practices

This article reports results from a systematic review used to inform the development of a best practice guideline to assist nurses in understanding their roles and responsibilities in promoting safe and effective client care transitions. A care transition is a set of actions designed to ensure safe and effective coordination and continuity of care as clients experience a change in health status, care needs, health care providers, or location.

An Examination of the First 30 Days After Patients are Discharged to the Community From Hip Fracture Postacute Care

BACKGROUND

Postacute care (PAC) rehabilitation aims to maximize independence and facilitate a safe community transition. Yet little is known about PAC patients' success in staying home after discharge or differences on this outcome across PAC providers.

OBJECTIVES

Examine the percentage of PAC patients who remain in the community at least 30 days after discharge (ie, successful community discharge) after hip fracture rehabilitation and describe differences among PAC facilities based on this outcome.

RESEARCH DESIGN

Retrospective observational study.

SUBJECTS

Community-dwelling, Medicare fee-for-service beneficiaries 75 years of age and above who experienced their first hip fracture between 1999 and 2007 (n=880,779). PAC facilities admitting hip fracture patients in 2006.

MEASURES

Successful community discharge, sites of readmission after PAC discharge.

RESULTS

Between 1999 and 2007, 57% of patients achieved successful community discharge. Black were less likely (adjusted odds ratios=0.84; 95% confidence interval, 0.82-0.86) than similar whites to achieve successful community discharge. Among all who reentered the community (n=581,095), 14% remained in the community <30 days. Acute hospitals (67.5%) and institutional PAC (16.8%) were the most common sites of reentry. The median proportion of successful community discharge among facilities was 49% (interquartile range, 33%-66%). Lowest-quartile facilities admitted older (85.9 vs. 84.1 y of age), sicker patients (eg, higher rates of hospital complications 6.0% vs. 4.6%), but admitted fewer annually (7.1 vs. 19.3), compared with the highest quartile.

CONCLUSIONS

Reentry into the health care system after PAC community discharge is common. Because of the distinct care needs of the PAC population there is a need for a quality measure that complements the current 30-day hospital readmission outcome and captures the objectives of PAC rehabilitation.

Family carers' experience of caring for an older parent with severe and persistent mental illness

While the burden of caring for older people with chronic medical illness and dementia has been well documented, considerably less is known about how carers develop the strength and resilience to sustain this important role with older family members with mental illness. The aim of the study was to understand the lived experience of primary caregivers of older people with severe and persistent mental illness, and to explore what, if anything, helps to sustain them in their caring role. An interpretative phenomenological analysis approach was adopted, and qualitative interviews were used with 30 primary caregivers. Two overarching themes, and related subthemes, were abstracted from the data. First, caring is a difficult and demanding responsibility. It affects carers adversely, emotionally, physically, socially, and financially, and their lifestyle in general. This is reflected in three subthemes: (i) physically and emotionally draining; (ii) grieving about the loss; (iii) and adverse effects on lifestyle and social relationships. Second, carers develop resilience in caring, which helps sustain them in their role, as illustrated in three subthemes: (i) caring as purposeful and satisfying; (ii) harnessing social support from others; and (iii) purposefully maintaining their own well-being. Community mental health nurses have a key role in assessing carers' needs and supporting them in their caring role.

Community-based primary health care for older adults: a qualitative study of the perceptions of clients, caregivers and health care providers

Background

Older persons are often poorly served by existing models of community-based primary health care (CBPHC). We sought input from clients, informal caregivers, and health care providers on recommendations for system improvements.

Methods

Focus group interviews were held with clients, informal caregivers, and health care providers in mid-sized urban and rural communities in Ontario. Data were analyzed using a combination of directed and emergent coding. Results were shared with participants during a series of feedback sessions.

Results

An extensive list of barriers, facilitators, and recommended health system improvements was generated. Barriers included poor system integration and limited access to services. Identified facilitators were person and family-focused care, self-management resources, and successful collaborative practice. Recommended system improvements included expanding and integrating care teams, supports for system navigation, and development of standardized information systems and care pathways.

Conclusions

Older adults still experience frustrating obstacles when trying to access CBPHC. Identified barriers and facilitators of improved system integration aligned well with current literature and Wagner’s Chronic Care Model. Additional work is needed to implement the recommended improvements and to discern their impact on patient and system outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-015-0052-x) contains supplementary material, which is available to authorized users.

Communicating during care transitions for older hip fracture patients: family caregiver and health care provider's perspectives

INTRODUCTION

Older hip fracture patients frequently require care across a variety of settings, from multiple individuals, including their family caregivers. We explored issues related to information sharing during transitional care for older hip fracture patients through the perspectives of both health care providers and family caregivers.

METHODS

Thirty-five semi-structured interviews were conducted with family caregivers (n = 9) and health care providers (n = 26) of six hip fracture patients to gather perspectives on information sharing at each care transition, beginning with post-surgical discharge from acute care. Data were analysed using conventional qualitative content analysis methods using NVivo8 software.

RESULTS

Both family caregivers and health care providers recognise that family caregivers' involvement has important benefits for patients, but this involvement is frequently limited by poor information sharing. Barriers include limited staff time, patient privacy regulations and lack of a clear structure to guide information sharing. Receiving, not offering, information was the focus of information sharing by both family caregivers and health care providers.

CONCLUSIONS

Specific barriers that lead to poor information sharing between family caregivers and health care providers have been identified in this study. Possible interventions to improve information sharing include encouraging communication with family caregivers as standard care practice, educational strategies and more effective use of health information systems and technologies.

Clinicians' views on improving inter-organizational care transitions

BACKGROUND

Patients with complex health conditions frequently require care from multiple providers and are particularly vulnerable to poorly executed transitions from one healthcare setting to another. Poorly executed care transitions can result in negative patient outcomes (e.g. medication errors, delays in treatment) and increased healthcare spending due to re-hospitalization or emergency room visits by patients. Little is known about care transitions from acute care to complex continuing care and rehabilitation settings. Thus, a qualitative study was undertaken to explore clinicians' perceptions of strategies aimed at improving patient care transitions from acute care hospitals to complex continuing care and rehabilitation healthcare organizations.

METHODS

A qualitative study using semi-structured interviews was conducted with clinicians employed at two selected healthcare facilities: an acute care hospital and a complex continuing care/rehabilitation organization, respectively. Analysis of the transcripts involved the creation of a coding schema using the content analyses outlined by Ryan and Bernard. In total, 31 interviews were conducted with clinicians at the participating study sites.

RESULTS

Three themes emerged from the data to delineate what study participants described as strategies to ensure quality inter-organizational transitions of patients transferred from acute care to the complex continuing care and rehabilitation hospital. These themes are: 1) communicating more effectively; 2) being vigilant around the patients' readiness for transfer and care needs; and 3) documenting more accurately and completely in the patient transfer record.

CONCLUSION

Our study provides insights from the perspectives of multiple clinicians that have important implications for health care leaders and clinicians in their efforts to enhance inter-organizational care transitions. Of particular importance is the need to have a collective and collaborative approach amongst clinicians during the inter-organizational care transition process. Study findings also suggest that the written patient transfer record needs to be augmented with a verbal report whereby the receiving clinician has an opportunity to discuss with a clinician from the acute care hospital the patient's status on discharge and plan of care. Integral to future research efforts is designing and testing out interventions to optimize inter-organizational care transitions and feedback loops for complex medical patients.

"Just another fish in the pond": the transitional care experience of a hip fracture patient

INTRODUCTION

Miscommunication and lack of coordination can compromise care quality and patient safety during transitions in care, especially for medically complex older adults. Little research has been done to investigate care transitions from the perspective of those receiving and providing care.

METHODS

This study explored multiple care transitions for an elderly hip fracture patient, post-surgery. Interviews and observations were conducted with the patient, their family caregivers, and health care providers, at each point of transition between four different care settings.

RESULTS

FOUR KEY THEMES WERE IDENTIFIED OVER THE PATIENTS CARE TRAJECTORY: 'Missing Crucial Coversations'-Patient and family caregivers did not feel involved or informed about decisions in care; 'Who's Who'-Confusion about the role of health care providers; 'Ready or Not'-Not knowing what to expect or what is expected; and, 'Playing by the Rules'-Health system policies and procedures hinder individualized care.

CONCLUSION

Study findings point to the need for the health care system to engage patients and family caregivers more fully and consistently in the process of care transitions as well as the importance of understanding these processes from multiple perspectives. Recommendations for system integration are proposed with a focus on transitional care.

Examining "success" in post-hip fracture care transitions: a strengths-based approach

Transitions between health care settings are a high-risk period for care quality and patient safety (Coleman, 2003; Picker Institute, 1999), particularly for older patients - such as those with hip fracture - who have complex needs and may undergo multiple care transitions. We sought to understand the key elements of "success" in care transition. Using a strengths-based perspective (Rapp, 1998; Saleebey, 2006), we focused on interprofessional health care providers' perspectives of what constitutes a "good" care transition for elderly hip fracture patients. As part of a larger ethnographic field study, semi-structured interviews were conducted with 17 health providers across a number of disciplines employed across the continuum of post-hip fracture management in British Columbia, Canada. We found two hallmarks of "success" in care transitions: a focus on process - information gathering and communication, and a focus on outcomes - autonomy and care pathways. Strategies for promoting and improving success, such as using practitioner-driven ground-up solutions to address challenges in care transitions, are highlighted.

"We don't have a back-up plan": an exploration of family contingency planning for emergencies following stroke

Little research has explored emergency preparedness among families coping with stroke. In this longitudinal qualitative study, we explored contingency caregiving planning by interviewing (N = 18) family caregivers providing care for a stroke survivor at home during the first 6 months post-discharge from the hospital. Emergent themes showed most families did not have a concrete "back-up plan" for a crisis or disaster situation involving the primary caregiver being unable to provide care. Furthermore, they assumed formal respite services or long-term care would be available should the need arise. Despite increased awareness over time, most caregivers had not devised contingency plans at 6 months.