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Achieving the transition from hospital to home: how older patients and their caregivers experience the discharge process #93-1

Carol L. McWilliam,  M.Sc.N., Ed.D., et al.

December, 1993


High health care costs and limited bed availability promote earlier discharge of hospital patients, who frequently return home with continued care needs. Because individuals 65 years and older have approximately twice as many hospital admissions and over twice as long an average length of stay, older patients are often affected by this health care trend. In our area, family physicians and other health professionals have expressed increasing concern about the interface between hospital services and home care delivery, fearing that older patients in particular may be having difficulty in making this transition.

Phenomenological study of the everyday experience of all involved in delivering health care has the potential to illuminate factors which escape scrutiny in traditional research and program evaluation approaches. This two-phased investigation therefore applied phenomenological research methodology to explore factors other than medical condition and treatments which contributed to the discharge experiences of 12 rural and 9 urban patients. Specifically, the research question asked: What factors other than diagnosis and treatment protocol contribute to the timing of discharge from hospital and the perceived adequacy of post-discharge care?

Interpretive research methods included document review, observation and in-depth interviews of all key participants. Over the two phases of the research, the purposefully selected sample consisted of a total of 21 patients over 65 years of age, and a change in sample of 22 informal caregivers, and 117 professionals and health care administrators involved in their care in the hospital and/or home setting. An immersion and crystallization analysis approach was used to identify three major themes which characterized discharge and readmission challenges: (1) professionally democratized order in the rural setting, versus bureaucratized order in the urban setting; (2) the disempowering process of interaction between both professional and family caregivers and older patients; and ultimately, (3) medicalization of care. These three factors combined to create 12 discharge delays for the 21 cases followed and re -admissions to hospital for 6 of the 21 patients during the 10-day post-discharge follow-up period. Findings suggest that to address such factors, health care system planners, administrators and professionals alike need to openly question their customarily narrow focus on individual organizational and role efficiency, dispense with the traditional hierarchical approaches, and begin to function as a collaborative team on which the patient is an equal member. The merits of efficient bed utilization, hospitalization, and opportunistic intervention might best be brought into open question routinely. Patients' own mindsets and sense of purpose in life require careful assessment in planning and implementing care. All professionals, patients, and the public in general require much better education about the full range of existing services and how to access them. System-wide approaches to tracking patients, and to planning, implementing, and evaluating health care delivery need to be put in place.