Background:
Frequent readmissions and transitions in care are inevitable for frail older adults with complex care needs. Upon discharge, the transfer home for vulnerable adults can be a critical phase in their care. To date, there has been wide global research and financial investment into processes to safely support frail older adults returning home from the hospital. Given the high burden and complexity of these populations, an exploration into issues, gaps, and possible solutions to improve this transition from hospital to home is warranted.
Aim:
This study aims to investigate clinicians’ perspectives on the transition from hospital to home and identify gaps in care for frail older adults during this transfer.
Methods:
A series of focus groups were conducted with clinicians using purposive sampling. Verbatim transcripts were analysed using reflexive thematic analysis (Braun and Clarke, 2006, Braun and Clarke, 2019). Themes were identified from the development of codes and relationships of core commonality.
Results:
A total of 28 clinicians participated in five focus groups. Participants included nurses, allied health, medical officers, managers and hospital executives. Themes derived from the focus groups were categorised into four different domains: (1) Navigating the complex health system in the context of finite resources, (2) Role of communication to ensure care coordination, (3) High patient complexity and vulnerability, and (4) Cultural and societal considerations in the process of aging.
Conclusion:
This research has contributed to a greater understanding of the experience of transitions in care within this local health context and the significant impact of navigating a complex health system for vulnerable populations. These learnings will directly inform the design and development of new interventions to support frail older adults in the high-risk journey from hospital to home.