Hospital to Home: Supporting the Transition From Hospital to Home for Older Adults

Abstract

Background An increasing proportion of older adults experience avoidable hospitalizations, and some are potentially entering long-term care homes earlier and often unnecessarily. Older adults often lack adequate support to transition from hospital to home, without access to appropriate health services when they are needed in the community and resources to live safely at home. Purpose This study collaborated with an existing enhanced home care program called Home Again in Nova Scotia, to identify factors that contribute to older adult patients being assessed as requiring long-term care when they could potentially return home with enhanced supports. Methods Using a case study design, this study examined in-depth experiences of multiple stakeholders, from December 2019 to February 2020, through analysis of nine interviews for three focal patient cases including older adult patients, their family or friend caregivers, and healthcare professionals. Results Findings indicate home care services for older adults are being sought too late, after hospital readmission, or a rapid decline in health status when family caregivers are already experiencing caregiver burnout. Limitations in home care services led to barriers preventing family caregivers from continuing to care for older adults at home. Conclusions This study contributes knowledge about gaps within home care and transitional care services, highlighting the importance of investing in additional home care services for rehabilitation and prevention of rapidly deteriorating health.

Applying the RE-AIM framework to evaluate a holistic caregiver-centric hospital-to-home programme: a feasibility study on Carer Matters

“…The study findings reiterated the need to advocate for a patient-caregiver dyadic hospital-to-home framework [11,36]. From a systems perspective, it is crucial to improve the integration of this care framework into existing care structures in two ways.…”

“…The approach of holistic caregiver support was appreciated and valued by caregivers, nurses, clinicians, and other healthcare providers. This complements the current hospital-to-home care delivery for patients, aimed at helping them thrive with a wellspring of support at home and beyond [11]. In the current system, typically only the very stressed caregivers who are in crisis and those with complex financial situations, are referred to the medical social workers.…”

“…The transition from hospital-to-home is a recognized critical opportunity to promote patient safety and highquality care for older adults and their caregivers [11]. Key mechanisms to equip such skills and knowledge include services such as care coordination and patient education [12].…”

“…Consequently, patient discharge outcomes such as readmission rates will improve, emphasizing the need for healthcare providers to offer those services [12]. However, transitional care support for older adults remains specifically focused on the needs of the patients [11]. This could ignore the essential role that caregivers play, and have potential repercussions on the recovery of the older adults.…”

A qualitative study of hospital and community providers’ experiences with digitalization to facilitate hospital-to-home transitions during the COVID-19 pandemic

“…Older adults are at a high risk of adverse health outcomes during hospital-to-home transitions [17][18][19][20][21][22]. Improving hospital-to-home transitions, particularly for older adults with complex care needs who transition more frequently due to higher care needs, is a high priority for health systems, including health service providers and researchers [23][24][25][26][27]. Coordinating hospital-to-home transitions is a complex task as multiple healthcare providers share the responsibility of care for a patient [28,29] and older adults with complex care needs have higher service needs [26].…”