Journal of General Internal Medicine

, Volume 32, Issue 10, pp 1114–1121 | Cite as

“Connecting the Dots”: A Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently Discharged Patients

  • Christine D. Jones
  • Jacqueline Jones
  • Angela Richard
  • Kathryn Bowles
  • Dana Lahoff
  • Rebecca S. Boxer
  • Frederick A. Masoudi
  • Eric A. Coleman
  • Heidi L. Wald
Original Research



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.

Key Results

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.


care 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.

Prior Presentations

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.

Supplementary material

11606_2017_4104_MOESM1_ESM.docx (13 kb)
ESM 1(DOCX 12 kb)


  1. 1.
    Jones CD, Ginde AA, Burke RE, Wald HL, Masoudi FA, Boxer RS. Increasing Home Healthcare Referrals upon Discharge from U.S. Hospitals: 2001-2012. J Am Geriatr Soc. 2015;63(6):1265–1266.CrossRefPubMedGoogle Scholar
  2. 2.
  3. 3.
    Bundled Payments for Care Improvement (BPCI) Initiative: General Information. 2017; Accessed 13 Feb 2017.
  4. 4. Research Statistics Data and Systems. 2016.
  5. 5.
    Jones CD, Wald HL, Boxer RS, et al. Characteristics Associated with Home Health Care Referrals at Hospital Discharge: Results from the 2012 National Inpatient Sample. Health Serv Res. 2017;52(2):879–894.CrossRefPubMedGoogle Scholar
  6. 6. Home Health Services. Accessed May 31, 2017.
  7. 7.
    Madigan EA, Gordon NH, Fortinsky RH, Koroukian SM, Pina I, Riggs JS. Rehospitalization in a national population of home health care patients with heart failure. Health Serv Res. 2012;47(6):2316–2338.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Avalere. Medicare Readmission Rates by State: Prepared for the Alliance for Home Health Quality and Innovation. 2016; Accessed 15 Feb 2016.
  9. 9.
    Hospital Compare. Accessed 1 May 2017.
  10. 10.
    Berland A, Bentsen SB. Medication errors in home care: a qualitative focus group study. J Clin Nurs. 2017.Google Scholar
  11. 11.
    Pesko MF, Gerber LM, Peng TR, Press MJ. Home Health Care: nurse-physician communication, patient severity, and hospital readmission. Health Serv Res. 2017.Google Scholar
  12. 12.
    Jones AL, Harris-Kojetin L, Valverde R. Characteristics and use of home health care by men and women aged 65 and over. Natl Health Stat Report. 2012(52):1–7.Google Scholar
  13. 13.
    Sockolow P, Bass EJ, Eberle CL, Bowles KH. Homecare Nurses' Decision-Making During Admission Care Planning. Stud Health Technol Inform. 2016;225:28–32.PubMedGoogle Scholar
  14. 14.
    Brega AG, Schlenker RE, Higgazi, K, Neal S, Belansky ES, Talkington S, Jordan AK, Bontrager J, Tennant C. Study of Medicare home health practice variations: final report. Denver, CO. August, 2002.Google Scholar
  15. 15.
    Centers for Medicare & Medicaid Services. Home Health Patient Tracking Sheet. Baltimore, MD: Centers for Medicare & Medicaid Services; 2009:24.Google Scholar
  16. 16.
    American Nurses Association. Home Health Nursing: Scope and Standards of Practice. 2nd ed. Silver Spring, MD: American Nurses Association; 2014.Google Scholar
  17. 17.
    Jones CD, Vu MB, O’Donnell CM, et al. A failure to communicate: a qualitative exploration of care coordination between hospitalists and primary care providers around patient hospitalizations. J Gen Intern Med. 2015;30(4):417–424.CrossRefPubMedGoogle Scholar
  18. 18.
    Bowles KH, Pham, J, O’Connor M, Horowitz DA. Information Deficits in Home Care: A Barrier to Evidence-Based Disease Management. Home Health Care Management Practice. 2010;22(4):278–285.CrossRefGoogle Scholar
  19. 19.
    McDonald KM, Sundaram V, Bravata DM, et al. Closing the quality gap: a critical analysis of quality improvement strategies (Vol. 7: Care Coordination). Rockville (MD). 2007.Google Scholar
  20. 20.
    Thomas DR. A General Inductive Approach for Analyzing Qualitative Evaluation Data. American Journal of Evaluation. 2006;27(2):237–246.CrossRefGoogle Scholar
  21. 21.
    Jones J, Nowels CT, Sudore R, Ahluwalia S, Bekelman DB. The future as a series of transitions: qualitative study of heart failure patients and their informal caregivers. J Gen Intern Med. 2015;30(2):176–182.CrossRefPubMedGoogle Scholar
  22. 22.
    Jones J, Nowels C, Kutner JS, Matlock DD. Shared decision making and the use of a patient decision aid in advanced serious illness: provider and patient perspectives. Health Expect. 2015;18(6):3236–3247.CrossRefPubMedGoogle Scholar
  23. 23.
    Kerr C, Nixon A, Wild D. Assessing and demonstrating data saturation in qualitative inquiry supporting patient-reported outcomes research. Expert Rev Pharmacoecon Outcomes Res. 2010;10(3):269–281.CrossRefPubMedGoogle Scholar
  24. 24.
    Hale J, Neal EB, Myers A, et al. Medication Discrepancies and Associated Risk Factors Identified in Home Health patients. Home Healthc Now. 2015;33(9):493–499.PubMedGoogle Scholar
  25. 25.
    Brody AA, Gibson B, Tresner-Kirsch D, et al. High Prevalence of Medication Discrepancies Between Home Health Referrals and Centers for Medicare and Medicaid Services Home Health Certification and Plan of Care and Their Potential to Affect Safety of Vulnerable Elderly Adults. J Am Geriatr Soc. 2016;64(11):e166-e170.CrossRefPubMedGoogle Scholar
  26. 26.
    Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–167.CrossRefPubMedGoogle Scholar
  27. 27.
    S. 578 — 114th Congress: Home Health Care Planning Improvement Act of 2015. 2015.Google Scholar
  28. 28.
    Bielaszka-DuVernay C. The 'GRACE' model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431–434.CrossRefPubMedGoogle Scholar
  29. 29.
    Avalere. Home health chartbook 2015: Prepared for the Alliance for Home Health Quality and Innovation. 2016. Accessed 15 Dec2016.
  30. 30.
    Harris-Kojetin L, Sengupta M, Park-Lee E, et al. Long-term care providers and services users in the United States: Data from the National Study of Long-Term Care Providers, 2013-2014. Vital Health Stat 2016; 3:105.Google Scholar
  31. 31.
    Landers S, Madigan E, Leff B, et al. The Future of Home Health Care: A Strategic Framework for Optimizing Value. Home Health Care Manag Pract. 2016;28(4):262–278.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  • Christine D. Jones
    • 1
    • 2
  • Jacqueline Jones
    • 3
  • Angela Richard
    • 3
    • 4
  • Kathryn Bowles
    • 5
    • 6
  • Dana Lahoff
    • 7
  • Rebecca S. Boxer
    • 7
  • Frederick A. Masoudi
    • 8
  • Eric A. Coleman
    • 4
  • Heidi L. Wald
    • 1
    • 4
  1. 1.Hospital Medicine Section, Division of General Internal MedicineUniversity of Colorado Anschutz Medical CampusAuroraUSA
  2. 2.University of Colorado Denver School of Medicine, Hospital Medicine DivisionAuroraUSA
  3. 3.College of NursingUniversity of Colorado Anschutz Medical CampusAuroraUSA
  4. 4.Division of Health Care Policy and ResearchUniversity of Colorado Anschutz Medical CampusAuroraUSA
  5. 5.School of NursingUniversity of PennsylvaniaPhiladelphiaUSA
  6. 6.Visiting Nurse Service of New YorkNew YorkUSA
  7. 7.Division of Geriatric MedicineUniversity of Colorado Anschutz Medical CampusAuroraUSA
  8. 8.Division of CardiologyUniversity of Colorado Anschutz Medical CampusAuroraUSA

Personalised recommendations