IntroductionComplex older adults, such as those with hip fracture, frequently require care from multiple professionals across a variety of settings. Integrated care both between providers and across settings is important to ensure care quality and patient safety. The purpose of this study was to determine the core factors related to poorly integrated care when hip fracture patients transition between care settings.MethodsA qualitative, focused ethnographic approach was used to guide data collection and analysis. Patients, their informal caregivers and health care providers were interviewed and observed at each care transition. A total of 45 individual interviews were conducted. Interview transcripts and field notes were coded and analysed to uncover emerging themes in the data.ResultsFour factors related to poorly integrated transitional care were identified: confusion with communication about care, unclear roles and responsibilities, diluted personal ownership over care, and role strain due to system constraints.ConclusionsOur research supports a broader notion of collaborative practice that extends beyond specific care settings and includes an appropriate, informed role for patients and informal caregivers. This research can help guide system-level and setting-specific interventions designed to promote high-quality, patient-centred care during care transitions.

IntroductionMiscommunication 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.MethodsThis 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.ResultsFour 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.ConclusionStudy 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.

There is growing recognition of the importance of sharing health information in home care; however, limited research exists to identify appropriate strategies, especially with home care providers. We engaged home care stakeholders from three locations in Ontario to determine facilitators, barriers, and recommendations for using health information in home care. The results suggest that health professionals recognize the potential of these systems to enhance communication through several emergent themes; however, there was a lack of agreement on the current facilitators, barriers, and recommendations for future interventions. More research is needed to achieve consensus before strategies for improvement can be initiated.