3021 — Transitions of Care from Hospital to Home for Older Veterans with Functional Limitations: Patient and Caregiver Perspectives
Dossa A (Center for Health Quality, Outcomes, and Economic Research, Bedford, MA), Bokhour BG
(Center for Health Quality, Outcomes, and Economic Research, Bedford, MA), Hoenig H
(Durham VAMC, Durham, NC)
Older Veterans with chronic complex disease and risk for functional decline are frequently discharged from the hospital to a home setting with continuing non-VA community nursing and rehabilitation services. Quality transition of care is essential for these patients to achieve optimal outcomes such as preventing readmissions and improving functional status. We examined patient and caregiver experiences with care transitions to home and community following hospital discharge for older Veterans with mobility impairments receiving rehabilitation services.
We conducted a qualitative longitudinal study of 18 participants (patients and caregivers). Patients were 70 years or older, had two or more chronic conditions, had received physical or occupational therapy as inpatients, had either medical or surgical diagnoses, and were recommended follow-up rehabilitation services at home. We conducted face-to-face semi-structured interviews two weeks post-discharge, and two telephone interviews at one and two months post-discharge. We asked about transition experiences including home discharge preparation, referral processes to follow-up services, and communication with providers. Audio-recordings of the interviews were transcribed verbatim and analyzed using grounded thematic analysis to identify emergent themes.
We identified four domains of communication issues impacting continuity of care and patient recovery: a) Poor communication between patients and providers regarding ongoing care at home, b) Whom to contact post-discharge, c) Provider response to phone calls following discharge, and d) Provider-provider communication. Many of these problems led to poor continuity of care and potentially to adverse outcomes including safety problems, increased pain, reduced function, delayed healing of bed-sores, and patient dissatisfaction.
Older patients with chronic complex disease and functional limitations have difficulty with post-acute communication with their providers. This may result in poor functional outcomes and safety issues at home.
Improved systems are needed to address patient concerns after discharge from the hospital and to facilitate recovery at home, particularly with regard to better coordination and communication between patients, hospital providers, and home care providers. In this era of shorter hospital stays for post-surgical or medical issues, more attention needs to be paid to ongoing care and recovery at home.