Health professional perspectives on systems failures in transitional care for patients with dementia and their carers: a qualitative descriptive study

Abstract

BackgroundHealthcare professionals engage in discharge planning of people with dementia during hospitalisation, however plans for transitioning the person into community services can be patchy and ineffective. The aim of this study was to report acute, community and residential care health professionals’ (HP) perspectives on the discharge process and transitional care arrangements for people with dementia and their carers.MethodsA qualitative descriptive study design and purposive sampling was used to recruit HPs from four groups: Nurses and allied health practitioners involved in discharge planning in the acute setting, junior medical officers in acute care, general practitioners (GPs) and Residential Aged Care Facility (RACF) staff in a regional area in NSW, Australia. Focus group discussions were conducted using a semi-structured schedule. Content analysis was used to understand the discharge process and transitional care arrangements for people with dementia (PWD) and their carers.ResultsThere were 33 participants in four focus groups, who described discharge planning and transitional care as a complex process with multiple contributors and components.Two main themes with belonging sub-themes derived from the analysis were:Barriers to effective discharge planning for PWD and their carers - the acute care perspective: managing PWD in the acute care setting, demand for post discharge services exceeds availability of services, pressure to discharge patients and incomplete discharge documentation.Transitional care process failures and associated outcomes for PWD – the community HP perspective: failures in delivery of services to PWD; inadequate discharge notification and negative patient outcomes; discharge-related adverse events, readmission and carer stress; and issues with medication discharge orders and outcomes for PWD.ConclusionsAlthough acute care HPs do engage in required discharge planning for people with dementia, participants identified critical issues: pressure on acute care health professionals to discharge PWD early, the requirement for JMOs to complete discharge summaries, the demand for post discharge services for PWD exceeding supply, the need to modify post discharge medication prescriptions for PWD, the need for improved coordination with RACF, and the need for routine provision of medication dose decision aids and home medicine reviews post discharge for PWD and their carers.

Health professionals’ perspectives on the discharge process and continuity of care for stroke survivors discharged home in regional Australia: A qualitative, descriptive study

“…This is similar to the recent National Stroke Audit data that reported, although 75% of stroke survivors needed ongoing rehabilitation, only 46% were referred to rehabilitation services (Stroke Foundation, ). The pressure to discharge patients quickly can mean that they do not receive information from all team members before they are sent home, and this is confirmed by other studies (Kable et al, ; Waring et al, ).…”

“…Discharge summaries should be completed and sent on the day of discharge. Routine provision of home medication reviews after discharge could contribute to reduced medication risk and fewer complications and readmission to hospital (Kable et al, ). Improved carer involvement and support might make it possible for carers to cope better and assist stroke survivors at home to avoid adverse outcomes (Hvalvik & Reierson, ; King et al, ; Naylor & Keating, ).…”

“…Health professionals involved in preparing patients for discharge have been described as well-intentioned and committed to planning for this transition. However, they can encounter organizational barriers, such as pressure to discharge patients, difficulty accessing services (Pindus et al, 2018), and incomplete discharge documentation, and carer stress that prevents the success of these plans (Kable, Chenoweth, Pond, & Hullick, 2015).…”

“…The impact of discontinuity on service delivery can result in delayed recovery and readmission to hospital (Naylor & Keating, 2008); carers might feel unsupported and that it is necessary for them to take responsibility to compensate for inadequacies in the health system (Hvalvik & Reierson, 2015). Previous studies about discontinuity in transitional care have been focused on older people (Cheen et al, 2017;Grealish et al, 2017;Hvalvik & Reierson, 2015) and people with dementia (Kable et al, 2015) or diminished cognition (Groene et al, 2012), carers of stroke survivors (King et al, 2010;Luker et al, 2017;Pindus et al, 2018), and general hospital admissions (Ziaeian, Araujo, Van Ness, & Horwitz, 2012). These studies have been conducted in Australia, Singapore, Norway, the USA, and Spain (participating in the HANDOVER project) (Groene et al, 2012), and results might be relevant to other similar health-care systems.…”

Frontline Healthcare Staffs’ Experience of Organizing Complex Hospital Discharges: An Ethnographic Study

“…Similarly, in Australia, a study by Kable, Chenoweth, Pond and Hullick (2015) demonstrates that Swedish studies also confirm these findings. For example, Ekdahl, Linderholm, Hellstrom, Andersson & Friedrichsen (2016) suggested that nurses are preoccupied with freeing up beds which led to failing to meet the high needs of elderly patients and this also generated feelings of guilt and frustration in the staff and contributed to making the patients feel unwelcome.…”