Experiences of frail older cardiac patients with a nurse-coordinated transitional care intervention - a qualitative study

Abstract

Background Older cardiac patients are at high risk of readmission and mortality. Transitional care interventions (TCIs) might contribute to the prevention of adverse outcomes. The Cardiac Care Bridge program was a randomized nurse-coordinated TCI combining case management, disease management and home-based rehabilitation for hospitalized frail older cardiac patients. This qualitative study explored the experiences of patients’ participating in this study, as part of a larger process evaluation as this might support interpretation of the neutral study outcomes. In addition, understanding these experiences could contribute to the design and application of future transitional care interventions for frail older cardiac patients. Methods A generic qualitative approach was used. Semi-structured interviews were performed with 16 patients ≥70 years who participated in the intervention group. Participants were selected by gender, diagnosis, living arrangement and hospital of inclusion. Data were analysed using thematic analysis. In addition, quantitative data about intervention delivery were analysed. Results Three themes emerged from the data: 1) appreciation of care continuity; 2) varying experiences with recovery and, 3) the influence of an existing care network. Participants felt supported by the transitional care intervention as they experienced post-discharge support and continuity of care. The perceived contribution of the program in participants’ recovery varied. Some participants reported physical improvements while others felt impeded by comorbidities or frailty. The home visits by the community nurse were appreciated, although some participants did not recognize the added value. Participants with an existing healthcare provider network preferred to consult these providers instead of the providers who were involved in the transitional care intervention. Conclusion Our results contribute to an explanation of the neutral study of a nurse-coordinated transitional care intervention. For future purpose, it is important to identify which patients might benefit most from TCIs. Furthermore, the intensity and content of TCIs could be more personalized by tailoring interventions to older cardiac patients’ needs, considering their frailty, self-management skills and existing formal and informal caregiver networks.

Health professionals’ experience of implementing and delivering a ‘Community Care’ programme in metropolitan Melbourne: a qualitative reflexive thematic analysis

“…Twelve (12) Four overall themes were produced from the data-rich interviews. The themes were (1) 'increasingly complex', (2) 'plugging the gaps', (3) 'disconnected' and (4) 'a misunderstood programme'.…”

“…Issues may include inadequate discharge notifications, 11 difficulty in linking patients into transitional care programmes and patients failing to see the importance of preventative care. 12 A transitional care coordination programme which operates from Peninsula Health, Victoria, Australia, known as Community Care, is a programme that sees the amalgamation of PAC, RIR and HARP services, 13 as can be seen in figure 1 .…”

Engaging patients in designing a transmural allied health pathway: A qualitative exploration of hospital‐to‐home transitions

“…On the one hand, this study depicts the positive experiences of participants who felt they could rely on allied health professionals who tailored therapy to their needs, ensured continuity of care and established a trusting relationship with the participants to reassure them and enhance their recovery. Providing tailored therapy, ensuring continuity of care, and establishing a trusting relationship with patients are essential goals to be reached by healthcare professionals as they can improve patient satisfaction, provide a sense of security, and increase adherence to prescribed treatments 26 . On the other hand, our study participants encountered negative experiences regarding communication with allied health professionals at the hospital after being discharged home and poor communication between hospital‐based and primary care‐based allied health professionals.…”

Relationship Between Frailty, Sociodemographic and Clinical Characteristics, and Disease Severity of Older Adults With Acute Coronary Syndrome

“…Understanding these sociodemographic and clinical factors and how they may be related to frailty will inform decision making toward tailored care and priority cases in primary prevention to prevent frailty or restore frail individuals. Awareness about these relationships will also enable structuring of transitional care, appropriate nurse-coordinated secondary prevention delivery in primary care, and cardiac rehabilitation following ACS (Jepma et al, 2021), thereby reducing the incidence of adverse events and related costs.…”

“…Specifically for patients with ACS, a secondary prevention intervention in the Netherlands included home visits following discharge for medication reconciliation, assessment for early signaling of health deterioration or complications (Jepma et al, 2021). To meet individuals’ needs in a flexible way, a nurse-led intervention following ACS in Sweden consisted of telephone-based follow-up with advice on lifestyle risk factors (i.e., diet, exercise, and smoking cessation) and medication adjustments according to the blood pressure and blood lipid measurements (Huber et al, 2017).…”