An examination of family caregiver experiences during care transitions of older adults.

This study explored informal family caregiver experiences in supporting care transitions between hospital and home for medically complex older adults. Using a qualitative, grounded-theory approach, in-depth semi-structured interviews were conducted with community and resource case managers, as well as with informal caregivers of older hip-fracture and stroke patients, and of those recovering from hip replacement surgery. Six properties characterizing caregiver needs in successfully transitioning care between hospital and home were integrated into a theory addressing both a transitional care timeline and the emotional journey. The six properties were (1) assessment of unique family situation; (2) practical information, education, and training; (3) involvement in planning process; (4) agreement between formal and informal caregivers; (5) time to make arrangements in personal life; and (6) emotional readiness. This work will support research and clinical efforts to develop more well-informed and relevant interventions to most appropriately support patients and families during transitional care.

"Just another fish in the pond": the transitional care experience of a hip fracture patient.

INTRODUCTION: Miscommunication and lack of coordination can compromise care quality and patient safety during transitions in care, especially for medically complex older adults. Little research has been done to investigate care transitions from the perspective of those receiving and providing care. METHODS: This study explored multiple care transitions for an elderly hip fracture patient, post-surgery. Interviews and observations were conducted with the patient, their family caregivers, and health care providers, at each point of transition between four different care settings. RESULTS: FOUR KEY THEMES WERE IDENTIFIED OVER THE PATIENTS CARE TRAJECTORY: 'Missing Crucial Coversations'-Patient and family caregivers did not feel involved or informed about decisions in care; 'Who's Who'-Confusion about the role of health care providers; 'Ready or Not'-Not knowing what to expect or what is expected; and, 'Playing by the Rules'-Health system policies and procedures hinder individualized care. CONCLUSION: Study findings point to the need for the health care system to engage patients and family caregivers more fully and consistently in the process of care transitions as well as the importance of understanding these processes from multiple perspectives. Recommendations for system integration are proposed with a focus on transitional care.

Bridging the information divide: health information sharing in home care.

As in many health sectors, in home care there have been significant investments made in electronic health information systems (EHIS) and accompanying standardized assessment instruments. While the potential of these systems to enhance the quality of care has been recognized, it has yet to be fully realized in Canadian home care settings. Data on EHIS barriers and facilitators were collected using a survey (n = 22).The results were discussed at a workshop (n = 30) and a "world café" session was held to consider strategies and interventions for improving health information exchange, with a focus on home care rehabilitation.

Developing an integrated system of care for frail seniors.

A consultation process was undertaken with healthcare providers in the Waterloo Wellington region of southern Ontario to assess current system strengths, challenges and gaps in providing care to frail seniors. The findings were used to implement strategies for improving system integration.