Transition Of Older Adults Research Articles

Difficult but achievable: medical social workers’ experiences transiting older adults from hospital care to nursing home in Nigeria

ABSTRACT Very few literatures have focused on transition of older adults from hospitals to nursing homes in African region. As a first step, this study explored the experience of medical social worker when transiting older adult from the hospital to nursing home in southwestern region of Nigeria. A descriptive qualitative approach collected through a semi-structured interview among 16 medical social workers showed that there is limited availability of nursing home facilities in Nigeria. Additionally, bureaucratic and administrative hurdles often added to the complexities of facilitating seamless transitions into nursing care homes. Cultural beliefs and family dynamics exert a substantial influence on the decision-making process, making the task of medical social workers even more intricate. There is a need for a greater support from policymakers and healthcare authorities to address the challenges facing Nigerian medical social workers. Hence, to better understand and address these experiences, the healthcare system can better equip medical social workers to navigate the transitions effectively and ensure the well-being of older adults during this crucial phase of their lives is adequately supported.

Prioritizing mobility factors for assessment during the transition of older adults from hospital to home: a cross-sectional survey of physiotherapists in Southeastern Nigeria.

Assessing all factors influencing older adults' mobility during the hospital-to-home transition is not feasible given the complex and time-sensitive nature of hospital discharge processes. To describe the mobility factors that Nigerian physiotherapists prioritize to be assessed during hospital-to-home transition of older adults and explore the differences in the prioritization of mobility factors across the physiotherapists' demographics and practice variables. This cross-sectional study included 121 physiotherapists who completed an online questionnaire, ranking 74 mobility factors using a nine-point Likert scale. A factor was prioritized if ≥ 70% of physiotherapists rated the factor as "Critical" (scores ≥7) and ≤ 15% of physiotherapists rated a factor as "Not Important" (scores ≤3). We assessed the differences in the prioritization of mobility factors across the physiotherapists' demographics/practice variables using Mann Whitney U and Kruskal-Wallis tests. Forty-three of 74 factors were prioritized: four cognitive, two environmental, one financial, four personal, eighteen physical, seven psychological, and seven social factors. Males and those with self-reported expertise in each mobility determinants more frequently rated factors as critical. Prioritizing many mobility factors underscores the complex nature of mobility, suggesting that an interdisciplinary approach to addressing these factors may enhance post-hospital discharge mobility outcomes.

Examining the Role of Third Sector Organization Volunteers in Facilitating Hospital-to-Home Transitions for Older Adults - a Collective Case Study.

With increasing attention to models of transitional support delivered through multisectoral approaches, third-sector organizations (TSOs) have supported community reintegration and independent living post-hospitalization. This study aimed to identify the core elements of these types of programs, the facilitators, and barriers to service implementation and to understand the perspectives of providers and recipients of their experiences with the programs. A collective case study collected data from two UK-based 'Home from Hospital' programs. An inductive thematic analysis generated rich descriptions of each program, and analytical activities generated insights across the cases. Programs provided a range of personalized support for older adults and addressed many post-discharge needs, including well-being assessments, support for instrumental activities of daily living, psychosocial support, and other individualized services directed by the needs and preferences of the service user. Results suggest that these programs can act as a 'safety net' and promote independent living. Skilled volunteers can positively impact older adults' experience returning home. When the programs under study are considered in tandem with existing evidence, it facilitates a discussion of how TSO services could be made available more widely to support older adults in their transition experiences.

PERSON-FIRST LANGUAGE FOR OLDER ADULTS INCARCERATED IN PRISON: A RAPID EVIDENCE ASSESSMENT

Abstract Language can influence a person’s sense of self, relationship with healthcare providers, healthcare utilization, or their own symptoms and behaviors. The person-first language movement began decades ago and has been widely adopted by multiple fields including nursing, medicine, gerontology, and social and health sciences more broadly. For research involving older adults, non-stigmatizing language has become the standard for researchers. Incarceration is widely considered a dehumanizing experience, with recent calls for attention to the language used by researchers when describing their incarcerated participants. Researchers are also identifying that individuals with multiple stigmatizing identities (e.g., incarcerated and disabled, older adult) warrant specific consideration. This study presents a secondary review of terminology from a Rapid Evidence Assessment (REA) investigating what is known about transitions of older adults in the incarceration system. The REA included PubMED, PscyhMED, and CINHAL. Nineteen articles met inclusion criteria (11 qualitative, 11 quantitative, 3 mixed methods). As a sub-analysis, articles were analyzed to consider the language that was used to describe the currently or formerly incarcerated older adults who were the subject of the studies. The majority of articles considered older adults who were no longer incarcerated. While person-first language (i.e., “formerly incarcerated person”, “reintegrating women”, “older adult on parole”) was common, stigmatizing language such as “prisoner”, “offender”, “homicide offender”, and “ex-convict” were used in the majority of the studies included in the review. Appreciation and adoption of person-first, non-stigmatizing language should transcend not only research literature surrounding older adults in the community, but also incarcerated older adults.

Perceived Impacts, Facilitators and Barriers to Optimize Hospital-to-Home Transitions for Older adults with Stroke and Multimorbidity through a Virtual Transitional Care Intervention

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 2.913 (2021 JCR, received in June 2022)The IJIC 20th Anniversary Issue was published in 2021.

Key Care Provision Aspects That Affect Care Transition in the Long-Term Care Systems: Preliminary Review Findings.

The aim of this brief report is to present the protocol and preliminary findings of a systematic review on key aspects of care provision that affect care transition of older adults 60+ within the long-term care systems. This brief report describes and classifies the relevant literature found in the review with the purpose to provide a base for further full systematic reviews, and to outlines a model of organizational and financing aspects that affect care transition. Our search was conducted in MEDLINE, Embase and CINAHL on 2 March 2020, before the COVID-19 pandemic. The protocol was registered at the International Prospective Register of Systematic Reviews (number: CRD42020162566). Ultimately, 229 full-text records were found eligible for further deliberation. We observed an increase in the number of publications on organizational and financial aspects of care transition since 2005. Majority of publications came from the United States, United Kingdom and Australia. In total, 213 (92%) publications discussed organizational aspects and only 16 (8%) publications were related to financial aspects. Records on organizational aspects were grouped into the following themes: communication among involved professional groups, coordination of resources, transfer of information and care responsibility of the patient, training and education of staff, e-health, education and involvement of the patient and family, social care, and opinion of patients. Publications on financial aspects were grouped into provider payment mechanisms, incentives and penalties. Overall, our search pointed out various care provision aspects being studied in the literature, which can be explored in detail in subsequent full systematic reviews focused on given aspects. We also present a model based on our preliminary findings, which enables us to better understand what kind of provision aspects affect care transition. This model can be tested and validated in subsequent research. Understating factors that affect care transition is crucial to improve the quality of transitions and ultimately the outcomes for the patients.

Recommendations for the Design and Delivery of Transitions-Focused Digital Health Interventions: Rapid Review.

BackgroundOlder adults experience a high risk of adverse events during hospital-to-home transitions. Implementation barriers have prevented widespread clinical uptake of the various digital health technologies that aim to support hospital-to-home transitions.ObjectiveTo guide the development of a digital health intervention to support transitions from hospital to home (the Digital Bridge intervention), the specific objectives of this review were to describe the various roles and functions of health care providers supporting hospital-to-home transitions for older adults, allowing future technologies to be more targeted to support their work; describe the types of digital health interventions used to facilitate the transition from hospital to home for older adults and elucidate how these interventions support the roles and functions of providers; describe the lessons learned from the design and implementation of these interventions; and identify opportunities to improve the fit between technology and provider functions within the Digital Bridge intervention and other transition-focused digital health interventions.MethodsThis 2-phase rapid review involved a selective review of providers’ roles and their functions during hospital-to-home transitions (phase 1) and a structured literature review on digital health interventions used to support older adults’ hospital-to-home transitions (phase 2). During the analysis, the technology functions identified in phase 2 were linked to the provider roles and functions identified in phase 1.ResultsIn phase 1, various provider roles were identified that facilitated hospital-to-home transitions, including navigation-specific roles and the roles of nurses and physicians. The key transition functions performed by providers were related to the 3 categories of continuity of care (ie, informational, management, and relational continuity). Phase 2, included articles (n=142) that reported digital health interventions targeting various medical conditions or groups. Most digital health interventions supported management continuity (eg, follow-up, assessment, and monitoring of patients’ status after hospital discharge), whereas informational and relational continuity were the least supported. The lessons learned from the interventions were categorized into technology- and research-related challenges and opportunities and informed several recommendations to guide the design of transition-focused digital health interventions.ConclusionsThis review highlights the need for Digital Bridge and other digital health interventions to align the design and delivery of digital health interventions with provider functions, design and test interventions with older adults, and examine multilevel outcomes.International Registered Report Identifier (IRRID)RR2-10.1136/bmjopen-2020-045596

Inclusion of Older Adults in Digital Health Technologies to Support Hospital-to-Home Transitions: Secondary Analysis of a Rapid Review and Equity-Informed Recommendations.

BackgroundDigital health technologies have been proposed to support hospital-to-home transition for older adults. The COVID-19 pandemic and the associated physical distancing guidelines have propelled a shift toward digital health technologies. However, the characteristics of older adults who participated in digital health research interventions to support hospital-to-home transitions remain unclear. This information is needed to assess whether current digital health interventions are generalizable to the needs of the broader older adult population.ObjectiveThis rapid review of the existing literature aimed to identify the characteristics of the populations targeted by studies testing the implementation of digital health interventions designed to support hospital-to-home transitions, identify the characteristics of the samples included in studies testing digital health interventions used to support hospital-to-home transitions, and create recommendations for enhancing the diversity of samples within future hospital-to-home digital health interventions.MethodsA rapid review methodology based on scoping review guidelines by Arksey and O’Malley was developed. A search for peer-reviewed literature published between 2010 and 2021 on digital health solutions that support hospital-to-home transitions for older adults was conducted using MEDLINE, Embase, and CINAHL databases. The data were analyzed using descriptive statistics and qualitative content analysis. The Sex- and Gender-Based Analysis Plus lens theoretically guided the study design, analysis, and interpretation.ResultsA total of 34 studies met the inclusion criteria. Our findings indicate that many groups of older adults were excluded from these interventions and remain understudied. Specifically, the oldest old and those living with cognitive impairments were excluded from the studies included in this review. In addition, very few studies have described the characteristics related to gender diversity, education, race, ethnicity, and culture. None of the studies commented on the sexual orientation of the participants.ConclusionsThis is the first review, to our knowledge, that has mapped the literature focusing on the inclusion of older adults in digital hospital-to-home interventions. The findings suggest that the literature on digital health interventions tends to operationalize older adults as a homogenous group, ignoring the heterogeneity in older age definitions. Inconsistency in the literature surrounding the characteristics of the included participants suggests a need for further study to better understand how digital technologies to support hospital-to-home transitions can be inclusive.

Recommendations made by patients, caregivers, providers, and decision-makers to improve transitions in care for older adults with hip fracture: a qualitative study in Ontario, Canada

BackgroundOlder adults frequently experience fall-related injuries, including hip fractures. Following a hip fracture, patients receive care across a number of settings and from multiple different providers. Transitions between providers and across settings have been noted as a vulnerable time, with potentially negative impacts. Currently, there is limited research on how to improve experiences with transitions in care following a hip fracture for older adults from the perspectives of those with lived experienced. The purpose of this study was to explore service recommendations made by patients, caregivers, healthcare providers, and decision-makers for improving transitions in care for older adults with hip fracture.MethodsThis descriptive qualitative study was part of a larger longitudinal qualitative multiple case study. Participants included older adults with hip fracture, caregivers supporting an individual with hip fracture, healthcare providers, and decision-makers. In-depth, semi-structured interviews were conducted with all participants, with patients and caregivers having the opportunity to participate in follow-up interviews as they transitioned out of hospital. All interviews were audio-recorded, transcribed verbatim, and analyzed thematically.ResultsA total of 47 participants took part in 65 interviews. We identified three main categories of recommendations: (1) hospital-based recommendations; (2) community-based recommendations; and (3) cross-sectoral based recommendations. Hospital-based recommendations focused on treating patients and families with respect, improving the consistency, frequency, and comprehensiveness of communication between hospital providers and between providers and families, and increasing staffing levels. Community-based recommendations included the early identification of at-risk individuals and providing preventative and educational programs. Cross-sectoral based recommendations were grounded in enhanced system navigation through communication and care navigators, particularly within primary and community care settings.ConclusionsOur findings highlighted the central role primary care can play in providing targeted, integrated services for older adults with hip fracture. The recommendations outlined have the potential to improve experiences with care transitions for older adults with hip fracture, and thus, addressing and acting on them should be a priority.

Systems Barriers to Medication Management During Hospital to Home Transitions of Older Adults With Dementia

The hospital-to-home transition is a high-risk period for medication errors and adverse events for older adults living with dementia. Researchers conducted a qualitative study using semi-structured interviews and participant solicited diaries. Caregivers of adults ages 55 and older were recruited to understand barriers to medication management during hospital to skilled home health care transitions. We used a human factors engineering approach to guide our understanding of systems level barriers. At least two researchers independently coded each transcript using content analysis and the ATLAS.ti software. We interviewed 23 caregivers and identified five barrier types stemming from systems breakdowns related to: (1) knowledge and information, (2) access to and use of resources and tools, (3) caregiver burden, (4) pandemic concerns, and (5) health limitations. Caregivers grappled with receiving overwhelming, insufficient, incorrect, or conflicting information, and had difficulty managing information from different sources. Latinx caregivers encountered language barriers that impeded role and task clarity. Caregivers expressed mistrust in health systems elements and inability to access resources. Caregivers were in need of additional caregiving assistance, financial aid, and tools to manage medications. Balancing multiple medications and responsibilities left caregivers burdened. The health limitations of the older adult and COVID-19 concerns related to reduced access to resources and ability to deliver and receive in person care complicated task management. Altogether these barriers reflect systems level breakdowns impeding task understanding, execution, and overall management. These findings will inform the development of interdisciplinary strategies to ensure safer care transitions.

Perceptions of a Transitional Care Model for Older Adults With Multimorbidity and Depressive Symptoms

Transitioning from hospital to home is an important healthcare system priority. This paper reports on the qualitative findings from a larger mixed methods study designed to examine the implementation and effectiveness of a new transitional care intervention (Community Assets Supporting Transitions [CAST]). The goal of the CAST intervention is to improve the quality and experience of hospital-to-home transitions for older adults (≥ 65 years) with depressive symptoms and multimorbidity. Semi-structured interviews were completed with a sub-set of intervention group trial participants including 11 older adult participants and 1 caregiver, as well as 4 intervention nurses. A qualitative descriptive design was used to explore the perceived impacts of the CAST intervention on participants and their caregivers. Audio-recorded interviews were transcribed verbatim, with descriptive codes and themes generated using conventional content analysis. Patient participants indicated that the intervention resulted in improved access to information (e.g., medication review) and services (e.g., care coordination) that enhanced their self-management. Participants felt that the home visits and phone visits were valuable and helped to improve their mental health. Intervention nurses described advocating for patients to help achieve their needs. For example, nurses advocated for physiotherapy services to provide additional education to support patient mobility. Understanding patient, caregiver, and provider perceptions of the impact of the CAST intervention will help to identify how to improve the delivery of this transitional care intervention, to bridge the gap between hospital and community care, and to positively impact patient health outcomes.

What’s Driving SNF Readmission Rates? Exploring Differences in Processes Between High and Low Performing Hospitals

Despite the increasing national focus on improving post-acute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this rapid ethnographic study was to observe processes used to prepare older patients for post-acute care in SNFs, and to explore differences between hospital-SNF pairs with high or low thirty-day readmission rates. We stratified hospitals according to readmission rates from SNF and used convenience sampling to identify two high and two low performing sites and associated SNFs (n=5). We conducted intensive multi-day observations (n=148 hours) and key informant interviews (n=30 clinicians) to describe hospital processes for discharging patients to SNF. We used thematic analysis of interviews and fieldnotes to identify differences in transitional care processes of hospitals discharging patients to SNFs. Hospitals used five major processes prior to SNF discharge that could affect care transitions for older adults: recognizing the need for post-acute care, deciding level of care, selecting SNF facility, negotiating patient fit, and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: 1) earlier, ongoing, systematic identification of high-risk patients; 2) discussing the decision to go to a SNF as an iterative team-based process; and 3) anticipating barriers with knowledge of transitional and SNF care processes. Identifying variations in processes used to prepare patients for SNF provides critical insight into the best-practices for transitioning patients to SNFs and areas to target for improving care of older adults.

Physiotherapists’ role during hospital-to-home transition for older adults with hip fracture and mobility limitation: A research protocol

Introduction Functional deficits such as gait speed, muscle strength or reduced activities in daily living after discharge are predictors for hospital readmission for older adults with hip fractures. However, physiotherapists (PTs) who are inherently mobility experts, do not actively participate during the hospital-to-home transition of older adults with hip fractures in the developing countries, including Nigeria. This qualitative study aims to describe and explore how PTs working within inpatient rehabilitation units prepare older adults (≥60 years) with a hip fracture for transfer to their home in the community. Methods We will adopt Sally Thorne’s Interpretive Description approach to purposively select 25 PTs with 5-years experience of participating in discharging older adults with hip fractures from inpatient rehabilitation-to-home. Data collection will include (a) semi-structured, one-on-one interviews with PTs, (b) discharge summaries of two older adults, and (c) final focus group discussion with PTs. We will ask the physiotherapists to provide discharge summaries of two older adults - one that they described as a “difficult” case and one that they described as an “easy” case during inpatient rehabilitation-to-home transition. Data will be analyzed employing Sally Thorne’s “borrowing techniques”- content and thematic analysis for the patients’ discharge summaries and PT interviews, respectively.

Optimizing Hospital-to-Home Transitions for Older Adults With Stroke and Multimorbidity

Optimizing Hospital-to-Home Transitions for Older Adults With Stroke and Multimorbidity

CONSISTENCY IN DOCUMENTATION OF TRIGGER EVENTS AND RELATED DIAGNOSES DURING 911 TRANSFERS TO ED NH RESIDENTS.

Previous research has identified that documentation practices during resident transitions from long-term care (LTC) to the emergency department (ED) can be inconsistent or nonspecific, leading to the receipt of inappropriate or insufficient care. When many older adults (>65 years) in LTC have cognitive impairments that make communication difficult and changes in resident health can present ambiguously, consistent documentation becomes particularly critical for the provision of safe, timely and appropriate care. The purpose of this study was to examine documentation practices across care settings related to reason for transfer during transitions of older adults from LTC to the ED. We tracked every resident transfer from 38 participating LTC facilities to two included EDs in two Western Canadian provinces from July 2011 to July 2012. Using case-related data gathered from 637 transitions, we employed qualitative content analysis to categorize whether documentation practices from LTC to the ED were sufficiently reported and clinically consistent. Transitions were defined as consistent when symptomatology, trigger events and diagnoses aligned in a medically-intuitive manner. Inconsistency patterns were further categorized as minor (indicating one outlying symptom/trigger) and major (indicating more than two inconsistencies). Of the total 637 transitions, 2.67% contained too little data to be accurately categorized. The majority of cases (75.82%) of cases had consistent documentation, 13.19% had minor inconsistencies, and 8.32% had major inconsistencies. These results support that shared continuing education for documentation practices should occur across care settings to ensure that documentation practices are sufficient, support a geriatric focus and consider differing clinician perspectives.

EXPLORING OLDER ADULTS’ EXPERIENCES IN CARE TRANSITIONS

Older adults are Canada’s largest growing demographic. Later adulthood is frequently accompanied by increased comorbidities, resulting in more people living with chronic conditions for longer portions of their lives and requiring care across multiple settings. These individuals are also the most susceptible to challenges within health care systems, especially during vulnerable times such as care transitions, which can be challenging due to issues of care integration and coordination. A scoping review was conducted to explore the experiences of older adults transitioning through various levels of care. The main themes found included personal realizations, social connectedness, importance of navigating the system and recommendations for the future. During care transitions, older adults must carefully consider their personal circumstances and limitations and often accept a new baseline, thus, adapting their lives and activities to match possible limitations. Older adults indicate the need for strong social networks, accessible and available services, as well as effective communication, information, education and engagement during care transitions. Issues with care transitions can be exacerbated in smaller communities, where resources and services may be limited. As such, this scoping review is the foundation for an ongoing systematic review which aims to summarize what is known about care transitions for older adults living in small and rural communities. By better understanding the different interacting factors that might influence care transitions for older adults living in small communities, important and sustainable changes can be identified and implemented to ensure that care transitions for older adults are safe, positive and empowering.

A FRAMEWORK FOR CARE TRANSITIONS FOR OLDER ADULTS WITH COMPLEX HEALTH CONDITIONS

For older adults with complex health conditions, transitions between care settings are common and a major risk to quality of care and patient safety. Care transition interventions have shown positive impacts on continuity of care and health service use, however, most require additional human resources (e.g., transition coach), focus on one transition or “handoff”, and provide support for individual patients without addressing underlying challenges of health system integration. We sought to develop a framework for system-level enhancements to care transitions for older adults. We report a secondary framework analysis of an ethnographic investigation (the “InfoRehab” project) of care transitions for older persons who had experienced a hip fracture. The ethnographic study involved interviews, observations, and document reviews for 23 patients, 19 family caregivers, and 92 health care providers. Data were collected at each transition point (1-4/patient) along the care continuum, at three Canadian sites (large urban, mid-size urban, rural). Our framework analysis followed the approach described by Gale et al. (2013), using as cases 12 peer-reviewed papers which had reported InfoRehab results. Two researchers coded findings from each paper, then developed an analytical framework of eight themes by consensus; these include: patient involvement and choice, family caregiver involvement, patient complexity, health care provider coordination, information sharing, documentation, system constraints, and relationships. NVivo 11 was used to index findings into these themes and to generate a matrix. We are working with system stakeholders, including patients and caregivers, to apply this framework in the development of improved systems for care transitions.

PREDICTORS OF PRESSURE ULCER DEVELOPMENT AMONG SENIORS DURING EMERGENCY TRANSFERS TO HOSPITAL EMERGENCY DEPARTMENT

Emergency transfers of seniors in long-term care facilities (LTCF) aged >65 to hospital emergency departments (ED) are common and carry with them risks that can lead to less-than-optimal quality of care and quality of life. Pressure ulcers are one such risk. We used data from the Older Persons Transitions in Care (OPTIC; N=637) study, conducted in two Canadian provinces in 2011 and 2012, to assess potential predictors of pressure ulcer development between the time that a resident is transported to the ED until the time they return to their original nursing home. Step-wise binary logistic regression was employed to identify predictors of pressure ulcer development during the transition. Potential predictors included length of transition, inpatient status, demographic, health variables (including incontinence). Among the 335 residents for whom we were able to gather new pressure ulcer data, 56 (16.7%) were identified as having developed new skin wounds upon return to the LTCF. Transitions from ED admission to return to LTCF averaged 106.7 hours (sd=143.6) with a median of 50.0 hours. Length of transition and whether the resident spent time as an inpatient emerged as the only predictors: longer transition times and spending time as an inpatient predict development of bed sores. These results speak to the need for improved monitoring and treatment of skin wounds during emergency transitions of older adults from LTCF.

The Role of Rehabilitation Professionals in Care Transitions for Older Adults: A Scoping Review

Aim: To identify existing theories and conceptual models that inform care transition interventions and to explore whether the role of rehabilitation professionals is explicitly stated or implied in these theories and models.Methods: We searched multiple databases and included articles published from 2000 to 2018, with distinct mention of care transitions of older adults (>65 years) from one care setting to another.Result: Two theories (Middle Range Theory and System of Care Philosophy), and six conceptual models (Coleman’s Model, 4Cs of Transitional Model, Quality Cost Model of Advanced Practice Nurses Transitional Care, Health Belief Model, Care Transition Framework, Ideal Transition in Care) were identified in 13 of the 21 articles; however, only one conceptual model in an opinion paper illustrated the role of a physiotherapist in care transition.Conclusion: Most of the models, frameworks and theories that inform care transition interventions did not explicitly consider the role of RPs.

Eliciting nurses’ perspectives to improve health information exchange between hospital and home health care

Despite patient safety initiatives to improve care transitions, prior research largely neglects to elicit feedback from home health nurses regarding health information exchange. The goal of this quality improvement study was to identify opportunities to facilitate information transfer during hospital-to-home-health-care transitions for older adults with heart failure. We conducted focus groups with 19 nurses employed by a single healthcare system using two commercially available electronic health record (EHR) vendors. We analyzed interview transcripts following an immersion/crystallization approach to identify themes. Average participants were females in their mid-fifties with 15 years of home health experience. Nurses reported challenges with hospital-to-home-health-care information exchange, specifically: 1) poor medication management, 2) ineffective communication, 3) technology issues, and 4) patient factors. Nurses identified several opportunities for improvement, including discordant EHR-generated medication lists, which may be amenable to technological solutions. Local quality improvement efforts should incorporate nurses’ suggestions and leverage existing best practices.