Patients' and Caregivers' Transition from Hospital to Home: Needs and Recommendations

Abstract

Given the greatly decreased length of hospital stays, concern about the transition from hospital to home has increased. This descriptive study focused on a sample of hospitalized patients discharged to home with home care services. Patient and caregiver interviews revealed that satisfaction with home care services was positively related to receipt of information from the home care staff about medications, equipment/supplies, and self-care. Caregiver burden was inversely related to receiving this information. Recommendations for improving the transition from hospital to home included providing more information, more reassurance and emotional support, and more household assistance. Several possible methods of implementing these recommendations are proposed.

Age-Related Differences in Perception of Quality of Discharge Teaching and Readiness for Hospital Discharge

“…11 Hindrances to care transitions are linked to poor patient outcomes, patient and family dissatisfaction, rehospitalization, or inappropriate use of emergency room or urgent care facilities. 8,11 Anticipatory assessment of discharge needs for older adults can be difficult because patients may not anticipate obstacles to daily living at home while still hospitalized [14][15][16] and may be reluctant to complain to avoid being perceived as ungrateful. 7 Failure to assess and identify postdischarge needs before or during the hospitalization allows them to emerge during the post-hospitalization period as problems or adverse events.…”

Further Application of the Care Transitions Intervention: Results of a Randomized Controlled Trial Conducted in a Fee-For-Service Setting

“…Patients and family caregivers consistently report inadequate support and unmet needs during care transitions. They are often unprepared for their self-management role in the next care setting, receive conflicting advice regarding chronic illness management, are often unable to reach an appropriate health care practitioner who has access to their care plan when questions arise, and have minimal input into their care plan (Coleman, 2003;Coleman et al, 2002;Grimmer, Moss, & Gill, 2000;Harrison & Verhoef, 2002;Levine, 1998;vom Eigen, Walker, Edgman-Levitan, Cleary, & Delbanco, 1999;Weaver, Perloff, & Waters, 1998). As a result of inadequate support and guidance offered by the health delivery system, patients and family caregivers are often faced with the task of assuming a substantial role in performing their care coordination activities.…”

Challenges Faced by Patients with Low Socioeconomic Status During the Post-Hospital Transition

“…13 In order to reduce disparities, hospitals and providers will need a deeper understanding of factors that drive poor transition outcomes for low-SES patients. Prior studies suggest that, in general, patients and caregivers attribute failed transitions to a lack of preparedness for discharge, [14][15][16][17] a sense of exclusion from discussions of the care plan, 14,18 abandonment by the health care system after discharge 15,19 and lack of adherence to discharge recommendations. 20,21 Despite the fact that low-SES patients are at higher risk for poor outcomes, few prior studies specifically explore the perspectives of these patients.…”