Understanding Stakeholder Insights on Transitional Care Needs: Enhancing Patient Outcomes

Introduction

In China, over 75.8% of elderly individuals have at least one chronic disease. As they age, the risk of multiple chronic conditions increases. This trend highlights the frequency of aging with illness among older adults. Elderly patients often move between various healthcare settings, particularly during the hospital-to-home transition. These transitions can lead to fragmented care due to their complex health needs.

During hospital stays, elderly patients rely heavily on healthcare staff. However, after discharge, many face challenges with self-care due to limited knowledge and skills. This burden is intensified by a lack of supportive healthcare services after leaving the hospital. Consequently, there is a heightened risk of negative health outcomes, including unplanned readmissions, affecting nearly 25% of elderly patients during this period. To mitigate these readmissions, transitional care services are recommended.

This study aims to evaluate the care needs of elderly patients in Shanxi Province during their transition from hospital to home. The goal is to improve transitional care services and enhance health outcomes for these individuals.

Methods

Study Design

The study used a qualitative research approach, employing semi-structured interviews to delve into the needs of elderly patients, their caregivers, and healthcare professionals during transitional care. The research adhered to COREQ guidelines.

Participants

Participants were recruited from Shanxi Bethune Hospital between June and December 2023. A purposeful sampling method was applied to include diverse perspectives, considering age, gender, education, and chronic conditions.

Inclusion Criteria for Elderly Patients:

1. Age 60 or older.
2. Discharged from a tertiary hospital.
3. Capable of participating without communication barriers.
4. Having at least one chronic disease.
5. Provided informed consent.

Exclusion Criteria:

1. Severe cardiovascular or cerebrovascular diseases, liver or kidney failure.
2. Terminal illness.
3. Cognitive impairments.

Inclusion Criteria for Caregivers:

1. Primary caregiver for at least three months.
2. Family members of the patients.
3. Willing to share their thoughts.

Exclusion Criteria:

1. Communication barriers.

Inclusion Criteria for Nurses:

1. Holding a middle-level or higher professional title.
2. At least five years of geriatric nursing experience.
3. Provided transitional care before.
4. Willing to participate.

Exclusion Criteria:

1. Undergoing training or advanced studies.

Procedure

Interviews were conducted in the following order: first with elderly patients, then caregivers, followed by nursing staff. The authors informed participants about the study and obtained consent. Interviews continued until themes were saturated, ensuring comprehensive insights.

Data Collection

In-depth interviews lasted 30 to 60 minutes, conducted by trained research teams. All interviews were audio-recorded with participants’ consent, and non-verbal cues were documented. Interviews occurred in comfortable settings for mutual ease.

Data Analysis

The transcripts were analyzed using the Colaizzi method, which involved extracting significant statements and coding perspectives. This led to the identification of key themes related to transitional care needs.

Ethical Considerations

The study followed ethical principles, gaining approval from the Ethics Committee of Shanxi Bethune Hospital. Informed consent was obtained from all participants, ensuring confidentiality throughout the research process.

Results

Demographic Characteristics

The analysis of interviews with 10 elderly patients, five caregivers, and five nurses revealed consistent perspectives. The elderly patients were mostly men, aged 67 to 85 years. Caregivers were typically family members, aged between 32 and 86. Nurses were aged 32 to 41.

Results of the Interviews

Four main themes and twenty-three sub-themes emerged from the interviews, highlighting the transitional care needs of elderly patients.

Theme 1: Enhance Self-Care Abilities

• Disease-Related Knowledge: Elderly patients and caregivers need better understanding of managing chronic conditions.
• Activities of Daily Living: Patients require help to maintain daily activities as physical decline occurs.
• Instrumental Activities: Declining physical ability limits tasks like cleaning and cooking.
• Disease Management: Patients need support in managing health effectively and understanding medical processes.
• Physical Activity: Regular exercise is essential but challenging due to mobility issues.
• Safety and Injury Prevention: Education on reducing fall risks and creating safe environments is needed.

Theme 2: Professional Guidance

• Basic Life Care: Guidance in daily tasks and personal care is vital.
• Medication Management: Patients struggle to remember medication regimens.
• Dietary Guidance: Personalized dietary advice is necessary to manage health conditions better.
• Rehabilitation Guidance: Continued exercise and rehabilitation at home require professional support.

Theme 3: Social and Psychological Support

• Community Living Services: Access to community support, like meal services, is critical.
• Economic Support: Many face financial burdens that require assistance.
• Family Support: Emotional support from family members is essential for coping with post-discharge challenges.
• Peer Support: Emotional connections with peers can aid recovery and rehabilitation.
• Emotional Support: Professional counseling can alleviate anxiety or depression during recovery.
• Social Activities: Opportunities for social interaction improve psychological well-being.

Theme 4: Healthcare Service Resources

• Home Care Services: Regular visits from healthcare professionals are essential.
• Community Services: Local services can address minor health issues and provide guidance.
• Rehabilitation Institutions: Access to quality rehabilitation facilities is crucial.
• Emergency Services: Prompt medical responses are necessary for emergencies.
• Convenient Medical Services: Services need to be patient-friendly, reducing travel challenges.
• Communication Channels: Better access for doctors’ advice would alleviate anxiety for patients.

Discussion

The needs of elderly patients transitioning from hospital to home are complex. Healthcare services must focus on medical, psychological, and social aspects to ensure comprehensive support. The findings highlight the challenges faced by elderly patients due to fragmented care post-hospital discharge. Effective transitional care should prioritize these dimensions, especially given the limited home care resources in China.

Conclusion

This study identified four key themes: enhanced self-care, professional guidance, social support, and healthcare resources. Meeting these needs is crucial for ensuring smooth transitions from hospital to home. Healthcare providers must assess needs comprehensively before discharge and work collaboratively to implement effective interventions. These findings aim to improve transitional care for elderly patients.