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

Between July 2017 and February 2018, patients were recruited for participation in this study. Because the discharge destination plans could change multiple times in a hospitalization, the eligibility of patients for the study could change throughout hospitalization. To give further context about patients on this unit during the study timeframe, we completed a retrospective review of the 1,024 patient discharges from the unit and found that 38 patients met the eligibility criteria. Overall, 15 patients provided written consent (11 women and four men), and 11 completed interviews. The remaining four were unable to complete interviews due to a change in postdischarge plans that no longer included HHC (two patients) and hospital readmissions prior to interviews (two patients). In total, interviews were completed with 27 individuals: 11 patients, eight caregivers, and eight HHC clinicians (five nurses and three physical therapists). For five of the interviews, the patient and the caregiver requested to be interviewed together. In four cases, interviews were missing from the caregiver (one case), the HHC clinician (one case), or both the caregiver and the HHC clinician (two cases). Overall, perspectives were available from the complete triad of patients, caregivers, and HHC clinicians in seven cases, and perspectives were available from the patient and at least one other individual (ie, caregiver or HHC clinician) in two additional cases.

Patient interviews lasted an average of 43 minutes, caregiver interviews an average of 41 minutes, and HHC clinician interviews an average of 25 minutes. Patients were on average 66 years old (range 52-85 years), and most were women and white. Six of the patients had prior experience with HHC services, and five were new HHC patients. Primary diagnoses for patients included the following: sepsis (three cases), urinary tract or kidney infections (two cases), bone/hardware infections (two cases), Clostridium difficile infection (one case), acute respiratory failure with hypoxia (one case), aortic stenosis (one case), and acute pancreatitis (one case). For caregivers, the average age was 61 years, all were women, and they had a spouse or other family member in six cases and a nonfamily caregiver in two cases. HHC clinicians were an average of 40 years old, half were women, and the average time providing HHC was 4.4 years (Table 1).

We observed the two main themes of clear and unclear expectations for HHC after discharge. Clear expectations occur when the patient and/or caregiver have expectations for HHC that align with the services they receive. Unclear expectations occur when the patient and/or caregiver expectations are either uncertain or misaligned with the services they receive. Although not all interviews yielded codes about clear or unclear expectations, patients described clear expectations in five cases and unclear expectations in another five cases.

In nine cases with more than one perspective available, expectations were compared within cases and found to be clear (three cases), unclear (three cases), or discordant (three cases) across perspectives. For the discordant cases, the description of clear and unclear expectations differed between patients and either their caregiver or their HHC clinician. 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. In addition, the desire for assistance with personal care for patients such as showering and housekeeping was described by caregivers with unclear expectations. The results are organized into clear, unclear, and discordant expectations from the perspectives of patients, caregivers, and HHC clinicians within cases.