Quality in transitional care of the elderly: Key challenges and relevant improvement measures

Abstract

Introduction: Elderly people aged over 75 years with multifaceted care needs are often in need of hospital treatment. Transfer acrosscare levels for this patient group increases the risk of adverse events. The aim of this paper is to establish knowledge of quality in transitionalcare of the elderly in two Norwegian hospital regions by identifying issues affecting the quality of transitional care and based on these issues suggest improvement measures.Methodology: Included in the study were elderly patients (75+) receiving health care in the municipality admitted to hospital emergencydepartment or discharged to community health care with hip fracture or with a general medical diagnosis. Participant observationsof admission and discharge transitions (n = 41) were carried out by two researchers.Results: Six main challenges with belonging descriptions have been identified: (1) next of kin (bridging providers, advocacy, support,information brokering), (2) patient characteristics (level of satisfaction, level of insecurity, complex clinical conditions), (3) health carepersonnel’s competence (professional, system, awareness of others’ roles), (4) information exchange (oral, written, electronic), (5) context(stability, variability, change incentives, number of patient handovers) and (6) patient assessment (complex clinical picture, patient description,clinical assessment).Conclusion: Related to the six main challenges, several measures have been suggested to improve quality in transitional care, e.g. informationto and involvement of patients and next of kin, staff training, standardisation of routines and inter-organisational staff meetings.