Patient, Caregiver, and Clinician Perspectives on Expectations for Home Healthcare after Discharge: A Qualitative Case Study
BACKGROUND: Patients discharged from the hospital with skilled home healthcare (HHC) services have multiple comorbidities, high readmission rates, and multiple care needs. In prior work, HHC nurses described that patients often express expectations for services beyond the scope of skilled HHC.
OBJECTIVE: The objective of this study is to evaluate and compare expectations for HHC from the patient, caregiver, and HHC perspectives after hospital discharge.
DESIGN/PARTICIPANTS: This was a descriptive qualitative case study including HHC patients, caregivers, and clinicians. Patients were discharged from an academic medical center between July 2017 and February 2018.
RESULTS: The sample (N = 27) included 11 HHC patients, eight caregivers, and eight HHC clinicians (five nurses and three physical therapists). Patient mean age was 66 years and the majority were female, white, and had Medicare. We observed main themes of clear and unclear expectations for HHC after discharge. Clear expectations occur when the patient and/or caregiver have expectations for HHC aligned with the services received. Unclear expectations occur when the patient and/or caregiver expectations are uncertain or misaligned with the services received. Patients and caregivers with clear expectations for HHC frequently described prior experiences with skilled HHC or work experience within the healthcare field. In most cases with unclear expectations, the patient and caregiver did not have prior experience with HHC.
CONCLUSIONS: To improve HHC transitions, we recommend actively engaging both patients and caregivers in the hospital and HHC settings to provide education about HHC services, and assess and address additional care needs.
© 2019 Society of Hospital Medicine
Patients who are discharged from the hospital with home healthcare (HHC) are older, sicker, and more likely to be readmitted to the hospital than patients discharged home without HHC.1-3 Communication between clinicians in different settings is a key factor in successful transitions. In prior work, we focused on communication between primary care providers, hospitalists, and HHC nurses to inform efforts to improve care transitions.4,5 In one study, HHC nurses described that patients frequently have expectations beyond the scope of what skilled HHC provides,5 which prompted us to also question experiences of patients and caregivers after discharge with skilled HHC (eg, nursing and physical therapy).
In a prior qualitative study by Foust and colleagues, HHC patients and caregivers described disparate experiences around preparation for hospital discharge—patients expressed knowing about the timing and plans for discharge, and the caregivers frequently felt left out of this discussion.6 In other studies, caregivers of recently discharged patients have described feeling excluded from interactions with clinicians both before and after discharge.7,8 In another recent qualitative study, caregivers described uncertainty about their role compared with the HHC role in caring for the patient.9
As of 2016, a majority of states had passed the Caregiver Advise, Record, and Enable (CARE) Act, which requires hospitals to (1) record a family caregiver in the medical record, (2) inform this caregiver about discharge, and (3) deliver instructions with education about medical tasks that they will need to complete after discharge.10
