Hospital to home health care transition: patient, caregiver, and clinician perspectives.

Increasing national attention is focused on improving posthospital transitions. Home health patients are in an opportune position to provide insight into this transition as they resume care for themselves with informal caregivers and home health professionals. This qualitative study describes the experiences of patients, informal caregivers, and home health clinicians during the posthospital transition. A total of 40 patients, 35 informal caregivers, and 15 clinicians participated in this study. Patients recalled receiving discharge instructions but with few details and limited information about follow-up actions if they had problems. Discharge instructions were a versatile means of communication. Home health clinicians used these instructions to guide discussions with patients and their caregivers. Both informal caregivers and home health care clinicians emphasized the inadequate preparation of caregivers during the discharge process. More attention is needed to proactively engage informal caregivers and involve home health clinicians who can facilitate the implementation of discharge plans to improve patient outcomes.