Patient, Caregiver, and Clinician Perspectives on Expectations for Home Healthcare after Discharge: A Qualitative Case Study

Study Design

In this qualitative descriptive case study, we interviewed HHC patients, an involved caregiver, and the HHC clinician completing the first HHC visit within 7-14 days following hospital discharge. We chose this timeframe to allow patients to receive one or more HHC visits following hospital discharge.

Population

A convenience sampling strategy was employed to recruit a sample that would reflect a national sample of Medicare HHC patients based on age, sex, race, and ethnicity. Because a majority of HHC users in the United States are Medicare beneficiaries

• >65 years old,¹² eligibility was initially limited to patients
• >65 years old. Due to recruitment challenges, the age range was broadened to
• >50 years old in October 2017. Because our goal was to better understand the experience of general medicine patients with multiple comorbidities, we recruited patients from one general medicine unit at an academic hospital in Colorado. Patients on this unit were screened for eligibility Monday-Friday (excluding weekends and holidays) based on research assistant availability.

Criteria included are as follows: HHC referral, three or more comorbidities, resides in the community prior to admission (ie, not in a facility), cognitively intact, English speaking, and able to identify a caregiver participating in their care. Eligible patients were approached for written consent prior to discharge to allow us to contact them 7-14 days after discharge for an interview by phone or in their home, per their preference. At the time of consent, patients provided contact information for their informal caregiver. Caregiver eligibility criteria included the following: age ≥18 years and provides caregiving at least one hour a week before hospital discharge. HHC clinicians approached for interviews had completed the first HHC visit for the patient following discharge. Both caregivers and HHC clinicians provided verbal consent for interviews. All participants received a $25 gift card for participation in the study.

Framework and Data Collection

Our interview guides were organized by the Agency for Healthcare Research and Quality Care Coordination Framework, an approach we have taken in prior work.^4,5,13 We added questions about patient preparation and self-management support to build on findings from a prior study with HHC nurses and on prior work by Coleman and colleagues.^5,14 Sample questions from the interview guides for patients, caregivers, and HHC clinicians within key analysis domains are included in Appendix 1. The patient and caregiver interviews were completed by an individual with prior experience in social work and healthcare (SS). The HHC clinician interviews were completed by either this individual (SS) or a physician-researcher with experience in qualitative methods (CJ). Patients and caregivers could choose to be interviewed individually or together. All interviews were digitally recorded and transcribed verbatim.

Analysis

This study aimed to evaluate the clarity of expectations related to HHC after discharge within and across cases. We primarily explored domains of patient preparation, assessing needs and goals, and creating a plan of care for skilled HHC from patient and caregiver perspectives. Because qualitative work had been completed previously with HHC clinicians, HHC perspectives were used primarily for triangulation of perspectives about expectations where possible. The analysis team was composed of the two interviewers (SS and CDJ) and a qualitative methods expert (JJ). We used our established team-based inductive approach to develop themes around patient expectations and preparation for HHC, with deductive connections to the framework as applicable.^15,16 Two team members completed the initial coding after every one to three interviews to ensure the themes were developing iteratively. Group discussions including the third team member were used to resolve discrepancies and to complete a team-based iterative analysis until informational saturation for expectations after discharge was reached from the patient and caregiver perspectives (ie, no new codes were identified).¹⁷ Once the team reached informational saturation with codes, we recruited three additional patients to ensure no new codes were identified in key domains before concluding recruitment. ATLAS.ti version 7.5.17 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) was used to facilitate coding and analysis. This study was approved by the Colorado Multiple Institutional Review Board (protocol 17-0553).