Abstract
The successful transfer of an older patient between health care organizations requires open communication between them that details relevant and necessary information about the patient's health status and individual needs. The objective of this study was to identify and describe the process and content of the patient information exchange between nurses in home care and hospital during hospitalization of older home-living patients. A multiple case study design was used. Using observations, qualitative interviews and document reviews, the total patient information exchange during each patient's episode of hospitalization (n = 9), from day of admission to return home, was captured. Information exchange mainly occurred at discharge, including a discharge note sent from hospital to home care, and telephone reports from hospital nurse to home care nurse, and meetings between hospital nurse and patient coordinator from the municipal purchaser unit. No information was provided from the home care nurses to the hospital nurses at admission. Incompleteness in the content of both written and verbal information was found. Information regarding physical care was more frequently reported than other caring dimensions. Descriptions of the patients' subjective experiences were almost absent and occurred only in the verbal communication. The gap in the information flow, as well as incompleteness in the content of written and verbal information exchanged, constitutes a challenge to the continuity of care for hospitalized home-living patients. In order to ensure appropriate nursing follow-up care, we emphasize the need for nurses to improve the information flow, as well as to use a more comprehensive approach to older patients, and that this must be reflected in the verbal and written information exchange.
Highlights
The successful transfer of an older patient between health care organizations requires open communication between them that details relevant and necessary information about the patient’s health status and individual needs
We found that there was only one instance out of 102 patients in which a nursing transfer document was exchanged at hospital admission, while discharge notes were present in 69% (n = 70)
In none of the cases was there information provided from the home care nurses to the hospital nurses
Summary
The successful transfer of an older patient between health care organizations requires open communication between them that details relevant and necessary information about the patient’s health status and individual needs. Conclusions: The gap in the information flow, as well as incompleteness in the content of written and verbal information exchanged, constitutes a challenge to the continuity of care for hospitalized home-living patients. In order to ensure appropriate nursing follow-up care, we emphasize the need for nurses to improve the information flow, as well as to use a more comprehensive approach to older patients, and that this must be reflected in the verbal and written information exchange. Because of the complexity of their health conditions [1,2], older patients tend to have more frequent hospital admissions [3], use a higher number of other health care services [4], and experience a great array of care pathways across. We report findings from a study dealing with nurses’ information exchange during older patients’ transfer
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