UNMET TRANSITIONAL CARE NEEDS OF OLDER ADULTS DISCHARGED FROM HOME HEALTH CARE: A QUALITATIVE NEEDS ASSESSMENT

Abstract

Abstract Transitional care is widely recognized as a set of time-limited services to support older adults during transfers between settings and providers of care; however, little is known about services that prepare older adults and their caregivers for transitions from Home Health Care (HHC) to independent self-care at home. The objective of this study was to describe HHC patients and clinician perceptions of unmet needs after HHC discharge and recommendations to address them in future research. A multiple case-study design was used in a single large HHC organization in North Carolina. Data were collected using chart reviews of HHC records and semi-structured interviews with paired patients (or caregivers as proxy) and HHC clinicians (Nf17 pairs). A transitional care intervention model was used as a conceptual framework to guide framework analysis of interview transcripts. Most patients were White (65%) and female (53%) with mean age of 83 years. Clinicians were Registered nurses and Physical therapists. Across cases, 17 patient and clinicians pairs described three unmet needs: (1)skills for symptom management; (2)community-based support for transportation, food, social engagement, and health services; (3)in-home support to assist with safety, and activities of daily living. HHC patients recommended new services while clinicians emphasized the need for resources to improve their capacity to prepare patients for discharge. These findings will inform an innovative adaptation of transitional care and other supports to prepare older adults and caregivers for transitions from HHC to independent self-care at home. Future research should explore adding transitional care services to address these needs.