Essential information for transition of care for frail elderly patients in Japan: A qualitative study

Abstract

Background Information exchange between hospitals and primary care physicians is suboptimal. Most physicians are dissatisfied with the current referral process, and poor communication leads to negative care transition outcomes. Method To identify the key information needed for a successful transition of care, we conducted a qualitative study using consecutive, semistructured in‐person interviews and focus group sessions. We recruited five participants engaged in clinical work for individual interviews and 16 participants for focus groups. We analyzed all data using qualitative thematic analysis. All results were returned to the participants and modified based on their feedback. Results The five individual interviews provided a general picture of the current referral process and an interview guide for the following focus group sessions. The focus group discussions were used to identify the essential information needed at admission and discharge from the hospital. Essential information on hospital admission was as follows: (1) basic medical and care information, (2) care resources available at home, (3) the purpose of admission and the goals of care during hospitalization, and (4) status of advance care planning (ACP) and patient's will in an emergency. Essential information on hospital discharge was as follows: (1) clinical course, (2) explanation of medical condition during hospitalization, (3) status of ACP and patient's will in an emergency, and (4) medical procedures to be continued at home. Conclusions We identified the essential information needed for a successful transition of care in Japan. The clinical effectiveness of a template that contains the information identified in our study warrants further investigation.

Association of Fragmented Readmissions and Electronic Information Sharing With Discharge Destination Among Older Adults

“…One exception to the trend was home health; beneficiaries with and without Alzheimer disease who had fragmented readmissions in which both the admission and readmission hospitals shared an HIE had 9% to 15% increased odds of going home with home health compared with fragmented readmissions in which the admission and readmission hospitals did not share an HIE. This association may be due to the electronically available health information; for example, accessing notes from a previous hospitalization or from outpatient visits may provide information about a patient's goals of care 41,42 (ie, to avoid discharge to an SNF) or their baseline functional status. 43 Fragmented readmissions were associated with 24% higher odds of dying during the readmission in beneficiaries without Alzheimer disease, but there was no statistically significant difference in the odds of dying during the readmission in beneficiaries with Alzheimer disease.…”

Effectiveness of early care information transfer among home-dwelling frail elderly patients in Japan: A cluster randomized trial

“…At the time the study was conducted, there were no validated tools for information transfer in the care transition of the frail elderly with social and other care needs from the point of continuity of care; therefore, we developed a standardized early care referral template based on qualitative research. 17 In brief, we conducted semistructured in-person interviews with five participants and two focus group sessions with sixteen participants. Participants were PCPs, nurses, pharmacists, and care managers who were engaged in acute hospital settings or primary care settings in the community.…”