“Connecting the Dots”: A Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently Discharged Patients
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In 2012, nearly one-third of adults 65 years or older with Medicare discharged to home after hospitalization were referred for home health care (HHC) services. Care coordination between the hospital and HHC is frequently inadequate and may contribute to medication errors and readmissions. Insights from HHC nurses could inform improvements to care coordination.
To describe HHC nurse perspectives about challenges and solutions to coordinating care for recently discharged patients.
We conducted a descriptive qualitative study with six focus groups of HHC nurses and staff (n = 56) recruited from six agencies in Colorado. Focus groups were recorded, transcribed, and analyzed using a mixed deductive/inductive approach to theme analysis with a team-based iterative method.
HHC nurses described challenges and solutions within domains of Accountability, Communication, Assessing Needs & Goals, and Medication Management. One additional domain of Safety, for both patients and HHC nurses, emerged from the analysis. Within each domain, solutions for improving care coordination included the following: 1) Accountability—hospital physicians willing to manage HHC orders until primary care follow-up, potential legislation allowing physician assistants and nurse practitioners to write HHC orders; 2) Communication—enhanced access to hospital records and direct telephone lines for HHC; 3) Assessing Needs & Goals—liaisons from HHC agencies meeting with patients in hospital; 4) Medication Management—HHC coordinating directly with clinician or pharmacist to resolve discrepancies; and 5) Safety—HHC nurses contributing non-reimbursable services for patients, and ensuring that cognitive and behavioral health information is shared with HHC.
In an era of shared accountability for patient outcomes across settings, solutions for improving care coordination with HHC are needed. Efforts to improve care coordination with HHC should focus on clearly defining accountability for orders, enhanced communication, improved alignment of expectations for HHC between clinicians and patients, a focus on reducing medication discrepancies, and prioritizing safety for both patients and HHC nurses.
KEY WORDScare transitions care coordination home health care hospitalist primary care provider
The authors would like to acknowledge the valuable contributions of all study participants. The authors also wish to thank Sue Felton for her contributions.
Compliance with Ethical Standards
Dr. Christine D. Jones is supported by grant number K08HS024569 from the Agency for Healthcare Research and Quality for this work. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. This work was supported by a grant from the University of Colorado, School of Medicine, Department of Medicine, Division of General Internal Medicine.
This work was presented at the Society of Hospital Medicine meeting in San Diego, California on March 7, 2016 and at the American Geriatrics Society meeting in Long Beach, California, on May 19, 2016.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
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