Emergency department‐to‐community care transition barriers: A qualitative study of older adults

Abstract

Background Over one‐half of older adults are discharged to the community after emergency department (ED) visits, and studies have shown there is increased risk of adverse health outcomes in the immediate post‐discharge period. Understanding the experiences of older adults during ED‐to‐community care transitions has the potential to improve geriatric emergency clinical care and inform intervention development. We therefore sought to assess barriers experienced by older adults during ED‐to‐community care transitions. Methods We conducted a qualitative analysis of community‐dwelling cognitively intact patients aged 65 years and older receiving care in four diverse EDs from a single U.S. healthcare system. We constructed a conceptual framework a priori to guide the development and iterative revision of a codebook, used purposive sampling, and conducted recorded, semi‐structured interviews using a standardized guide. Two researchers coded the professionally transcribed data using a combined deductive and inductive approach and analyzed transcripts to identify dominant themes and representative quotations. Results Among 25 participants, 20 (80%) were women and 17 (68%) were white. We identified four barriers during the ED‐to‐community care transition: (1) ED discharge process was abrupt with missing information regarding symptom explanation and performed testing, (2) navigating follow‐up outpatient clinical care was challenging, (3) new physical limitations and fears hinder performance of baseline activities, and (4) major and minor ramifications for caregivers impact an older adult's willingness to request or accept assistance. Conclusions Older adults identified barriers to successful ED‐to‐community care transitions that can inform the development of novel and effective interventions.

Veteran knowledge, perceptions, and receipt of care following visits to VA emergency departments for ambulatory care sensitive conditions

“…Our study findings indicate that providing written discharge instructions is likely insufficient to enhance education for Veterans about their VA ED follow-up care. This finding echoes that of Gettel et al, 12 who interviewed older non-Veterans about their discharge experiences and found that lengthy ED discharge instructions were not helpful. Improving the quality of written instructions, through individualization, 34 illustrations, 35,36 and simplifications appropriate for patients at all levels of health literacy, 37,38 may make them more useful.…”

“…However, inadequate follow‐up care after ED visits and deficits in communication between ED and follow‐up care providers are common and worthy of attention 7 . Although improving post‐ED care has been prioritized by several commissions, accreditors, and funders, 2,8–11 there remains a relative paucity of evidence‐based practices for reducing care fragmentation across the ED treat‐and‐release transition; further study and intervention development are needed 2,12 …”

“…7 Although improving post-ED care has been prioritized by several commissions, accreditors, and funders, 2,[8][9][10][11] there remains a relative paucity of evidence-based practices for reducing care fragmentation across the ED treat-and-release transition; further study and intervention development are needed. 2,12 VA patients, who are generally older and have more complex medical histories than the general population, may have even greater care coordination needs following ED visits. 1,13 Concordantly, the VA Directive for Emergency Medicine (1101.05) emphasizes the importance of VA ED discharge transitions, stating that "a means of providing appropriate follow-up for patients seen and treated in the ED/Urgent Care Clinics must be available."…”

Emergency department care transition barriers: A qualitative study of care partners of older adults with cognitive impairment

“…In this work, we chose to focus on care partners of PLWCI, as the unique experiences of those with intact cognition would likely identify separate barriers and themes during the ED discharge care transition. 21 Described in greater detail below, PLWCI were identified through the electronic medical record as well as through in‐ED cognitive testing to additionally capture those with MCI. Historically, the presence of dementia or MCI has been underdocumented in the electronic medical record and underrecognized in the ED.…”

Patient experiences of a care transition intervention for Veterans to reduce emergency department visits

“…10 As an example in ED-based CTI research, one mixed-methods study found no change in 60-day acute care use in the intervention group; however, patient, provider, and coach interviews used to explore the reasons for return ED visits after the intervention revealed that structural features of the health care system (outside of the CTI itself) were a large driver of patient revisits. 2 Other previous work on CTIs in the ED setting has focused more generally on discharges and care transitions outside of any specific intervention, examining the perspectives of older adult patients, 11 patients and caregivers with an ED visit for a fall, 12 and ED providers. 13 There is a great need for more insight into the patient experience of a CTI itself.…”