Nicole E Werner1, Michelle Tong1, Amy Borkenhagen1, Richard J Holden2. 1. Department of Industrial and Systems Engineering, University of Wisconsin-Madison. 2. School of Informatics and Computing, Indiana University-Purdue University Indianapolis.
Abstract
BACKGROUND AND OBJECTIVES: Facilitating older adults' successful hospital-to-home transitions remains a persistent challenge. To address this challenge, we applied a systems lens to identify and understand the performance-shaping factors (PSFs) related older adults' hospital-to-home transition success. RESEARCH DESIGN AND METHODS: This study was a secondary analysis of semi-structured interviews from older adults (N = 31) recently discharged from a hospital and their informal caregivers (N = 13). We used a Human Factors Engineering approach to guide qualitative thematic analysis to develop four themes concerning the system conditions shaping hospital-to-home transition success. RESULTS: The four themes concerning PSFs were: (a) the hospital-to-home transition was a complex multiphase process-the process unfolded over several months and required substantial, persistent investment/effort; (b) there were unmet needs for specialized tools-information and resources provided at hospital discharge were not aligned with requirements for transition success; (c) alignment of self-care routines with transition needs-pre-hospitalization routines could be supportive/disruptive and could deteriorate/be re-established; and (d) changing levels of work demand and capacity during the transition-demand often exceeded capacity leading to work overload. DISCUSSION AND IMPLICATIONS: Our findings highlight that the transition is not an episodic event, but rather a longitudinal process extending beyond the days just after hospital discharge. Transition interventions to improve older adults' hospital-to-home transitions need to account for this complex multiphase process. Future interventions must be developed to support older adults and informal caregivers in navigating the establishment and re-establishment of routines and managing work demands and capacity during the transition process.
BACKGROUND AND OBJECTIVES: Facilitating older adults' successful hospital-to-home transitions remains a persistent challenge. To address this challenge, we applied a systems lens to identify and understand the performance-shaping factors (PSFs) related older adults' hospital-to-home transition success. RESEARCH DESIGN AND METHODS: This study was a secondary analysis of semi-structured interviews from older adults (N = 31) recently discharged from a hospital and their informal caregivers (N = 13). We used a Human Factors Engineering approach to guide qualitative thematic analysis to develop four themes concerning the system conditions shaping hospital-to-home transition success. RESULTS: The four themes concerning PSFs were: (a) the hospital-to-home transition was a complex multiphase process-the process unfolded over several months and required substantial, persistent investment/effort; (b) there were unmet needs for specialized tools-information and resources provided at hospital discharge were not aligned with requirements for transition success; (c) alignment of self-care routines with transition needs-pre-hospitalization routines could be supportive/disruptive and could deteriorate/be re-established; and (d) changing levels of work demand and capacity during the transition-demand often exceeded capacity leading to work overload. DISCUSSION AND IMPLICATIONS: Our findings highlight that the transition is not an episodic event, but rather a longitudinal process extending beyond the days just after hospital discharge. Transition interventions to improve older adults' hospital-to-home transitions need to account for this complex multiphase process. Future interventions must be developed to support older adults and informal caregivers in navigating the establishment and re-establishment of routines and managing work demands and capacity during the transition process.
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