Evaluating a transitional care program for the average and the oldest old: results from the qualitative phase of a mixed methods study

Abstract

In the light of an ageing population and the focus on ageing in place transitional care programmes for older adults who return home after hospitalisation become more important. The significant outcomes of on mortality, functional outcome and health care utilization within 3 months after discharge of these programme often are however unclear, minor or lacking. This study is a part of a larger sequential mixed methods study. Our first study described the quantitative evaluation the Transitional Care Bridge (TCB) programme in a regional hospital. The TCB programme included a visit of the community nurse (CN) in the hospital, handover of a treatment plan by the geriatric team and five home visits after discharge. The study part of the study did not demonstrate significant results. Therefore, in this qualitative part we shed a light on these result by collecting the perspectives and experiences of professionals and patients involved in the TCB programme.

In total 22 semi-structured interviews were held with 5 hospital nurses, 4 CN and 13 patients, sometimes with family members. Two focus group meetings were held with the geriatric team and a team that represented the five collaborating homecare organisations. A thematic analysis was conducted.

Nine themes were identified in the three different groups of participants. “Doing the right thing” and “Staying motivated over time” (hospital nurses), “Building relationship”, “Sharing the care”, “Expectations” and “Expertise”(CNs), and “Support”, “Reluctance accepting help” and “World becomes smaller” (patients). These intertwined themes reflect three categories: quality of care, motivation and relationships.

The TCB programme is valued, accomplished more patient satisfaction and work satisfaction. Additionally, it raised more awareness on care for older adults. There are, however, major issues concerning the delivery of the programme. The overall sentiment of professionals still working in their silos was described by some as “different worlds”. The central theme ‘Doing the right is bridging the worlds of expertise and expectations. These worlds seem separated and nurses seem to struggle between these two concepts. Expectations of each other and of the programme influenced motivation of the professionals and willingness of patients to participate in the programme. Enrolment in the programme was often depending on one professional ‘doing the right thing’ and was hindered by the strict boundaries, the focus on early discharge from hospital and capacity problems of geriatric team and CNs.

As patients tended to end the programme preliminary after their physical problems diminished, the real value of the programme was not entirely reached, which might have influenced the outcomes of the programme. The reluctance to accept support should be addressed during the programme, because by stopping the programme after the first few visits of the CN some needs remain unmet which compromises the goal of ageing in place. It is especially the role of the professional as the expert that needs reflecting upon as well as the positioning of the specific profession in the different contexts.

In the final phase of this mixed methods study the quantitative and qualitative outcomes will be combined, compared and interpreted.