Increasing national attention is focused on improving posthospital transitions. Home health patients are in an opportune position to provide insight into this transition as they resume care for themselves with informal caregivers and home health professionals. This qualitative study describes the experiences of patients, informal caregivers, and home health clinicians during the posthospital transition. A total of 40 patients, 35 informal caregivers, and 15 clinicians participated in this study. Patients recalled receiving discharge instructions but with few details and limited information about follow-up actions if they had problems. Discharge instructions were a versatile means of communication. Home health clinicians used these instructions to guide discussions with patients and their caregivers. Both informal caregivers and home health care clinicians emphasized the inadequate preparation of caregivers during the discharge process. More attention is needed to proactively engage informal caregivers and involve home health clinicians who can facilitate the implementation of discharge plans to improve patient outcomes.
Successful chronic care ideally involves patient engagement, but little is known about chronically ill older adults' ability to self-manage their health. This study examines activation among hypertensive patients older than 65 years. Almost 60% of participants scored in the bottom half of the activation scale; only 8% scored at the highest level. Higher activation was associated with higher self-ratings of health, health literacy, and receipt of patient-centered care, shorter lengths of stay, and lower depression and hearing impairment levels. Effective self-management support for chronically ill elders will likely require varied strategies and may need to address depression, health literacy, and/or hearing impairments.
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