The transition from hospital to home: an exploratory study.

With the predominance of the elderly and chronically ill, and shorter lengths of stay, hospitals struggle with facilitating timely discharge while ensuring that the patient and family receive proper ongoing care. Subsequently, facilitating the patient's smooth transition from hospital is of primary importance at the time of discharge. Yet, little is known about the situations and difficulties patients experience during the first week after discharge. This study explored the patient's transition from hospital to home. Using a random sample of adult medical-surgical patients, data was collected during the first week at home using telephone and in-depth interviews, and participant observation. The results of this study present four major themes: the nature of the patient's continuing care needs, the importance of an available and able caregiver, the presence of caregiver uncertainty, and the need for information. In addition, it identified home care services as a vital resource to assist patients with illness management. Further research is needed to examine the patient's transition home over time, to explore the importance of caregiver networks and information seeking after discharge, and to develop discharge planning methods which integrate hospital and community services.