Predictors of the need for post-discharge transitional care services in older adults: A cross-sectional analysis

Abstract

Chronic diseases in the growing elderly population lead to repeated hospitalizations and consequent deterioration of older adults' health, highlighting the importance of appropriate post-discharge patient care services during the care transition period from the hospital to their homes or a nursing facility. This study aimed to investigate older adults’ need for transitional care services (TCS) and identify the associated factors. A 1:1 phone survey was conducted on 300 older adults aged ≥65 years who resided in Gangwon Province, Republic of Korea. To identify predictors of older adults’ need for TCS, personal factors (sex, age, education level, residence, economic status), disease-related factors (self-rated health status, noncommunicable diseases and chronic conditions, hospitalization within the last 2 years), and care-related factors (spending time alone during daytime, need assessment of activities of daily living (ADLs), cohabitations) were examined, and the data were analyzed using descriptive statistics and multiple regression analysis. The results indicated that older adults exhibited a high need for TCS, with the greatest need being “information and training on self-management of health after discharge,” “information on social welfare (life support) services available near the patient’s living area,” and “description of the diagnosis, current condition, treatment plan, and outcome at the time of admission.” Additionally, the most common post-discharge difficulties experienced by older adults who had been hospitalized over the last 2 years were “physical discomfort” (3.7) and “psychological discomfort” (3.0). Hierarchical regression analysis revealed that noncommunicable diseases and chronic conditions (among disease-related factors) and need assessment of ADLs (among care-related factors) were identified as predictors of the need for TCS (β=0.206, p<0.001 and β=-0.171, p<0.01, respectively). Based on these results, we proposed the necessity to provide post-discharge TCS for elderly patients, especially older adults with multiple chronic diseases or those with poor ADLs, who should be prioritized for these services.