There’s nothing quite like flailing about in the dark trying to find the light-switch. It’s the middle of the night and you barely know your own name, let alone the lay-out of your home. Of course there are obstacles in your path, a chair that you definitely had not placed there.
You stand there, holding on to the chair that’s dented you, in pitch-black, thinking, ‘there’s got to be a better way, I know there is.’ Most of the participants in a recent study on transitions from hospital to home felt the same way; Confused by a process they thought was going to be straightforward and understandable, marred by obstacles they didn’t see coming, resulting in stress, utter confusion and isolation.
The Stakes are High
Seniors and their informal caregivers (unpaid) were studied by a global coalition of academics to highlight what was and wasn’t working in the vulnerable time between hospital and adjusting to home. Importantly, the study first established the stakes of getting this right. With a rapidly ageing world population, ever strained healthcare systems, the need for all to adapt to effectively meet the needs of older adults, particularly in transition-care management has never been so critical.
The study also addressed the existence and vital function of informal caregivers in eldercare, particularly in the transition time. From spouses and children to friends and neighbours, unpaid assistance to older adults must be acknowledged by public policymakers when looking at eldercare. The study proved they regularly bore “the burden of providing comprehensive care, navigating complex medical tasks, and managing older adults’ practical and emotional needs.”
Particularly in the time of transition from hospital to home, the study found that these challenges intensified, with caregivers managing elevated responsibilities, minimal support and heightened stress levels.
Up the creek without a paddle
For the senior patients and their caregivers studied, themes of loneliness and confusion in the transition process were prevalent. “Feelings of isolation and self-reliance, abrupt discontinuity of care, and lack of ongoing support and guidance characterized negative experiences.”
A senior participant likened their transition to, “a transactional experience characterized by abrupt farewells and a lack of ongoing guidance or support.” Echoing this feeling, another expressed “feeling frustrated and disheartened by the perceived lack of genuine care and support post-discharge.”
A participant directly told an interviewer, “It felt quite abrupt and impersonal, ‘OK, goodbye…next! My experience was far from simple, transcending a mere physical injury. Upon returning home, I was beset with questions about permissible activities, necessary lifestyle modifications, and overall future conduct.” Continuing, “Initially, I found myself consulting various medical professionals on a daily basis”.
Expressions of disappointment with the discontinuity of care once the hospitalization need was medically addressed highlighted to the researchers “the importance of ongoing support and follow-up beyond the hospital setting.”
A participant said, “I needed someone to advise me on the right course of action and assess whether I was proceeding correctly…There lacks a single entity who can oversee and coordinate my ongoing care.”
The researchers found that most senior participants would have preferred a relaxed process of going through discharge instructions rather than an abrupt discharge letter handed over.
Small pivot solves with big impacts
Of the participants who expressed happiness with their transition time, core approaches and solves emerged. From even short phone calls, and home visits, participants conveyed a feeling of being reassured and empowered.
The researchers importantly found that some transition processes allowed for reduced strain on the hospital system and resources of medical professionals in the long-run. With detailed written guidelines, medical professionals’ contact information and scheduled home visits patients and caregivers were able to feel instantly supported. They asked questions and received answers quickly with short phone-calls to a trusted and known healthcare professional. This reduced the run-around time of their carer trying to find someone to talk to, and potential for a return to the hospital and appointment times. Stress, isolation, resource strain and health decline were minimised for all parties by having a collaborative communication process in the immediacy of the transition time.
A participant praised, “It was reassuring to receive clear guidance and support. Additionally, I was given detailed written guidelines about dietary recommendations, including what foods to consume, what to avoid, and guidelines for healthy and unhealthy eating choices. Furthermore, they provided me with the contact number for the department of the professor who performed the surgery, should I have any questions”.
Short-term ‘helping hand’ for long-term gain
A fragmented medical system and generic transition care were particular sticking points for participants. Navigating the fog of medications, treatments and follow-up care, without a clear person to ask for clarity, intensified the stress and loneliness for both senior and carer.
In a time of acute stress the participants just wanted a helping hand. Establishing processes of focused discharge attention, clarity of communication and follow-up channels of communication are ways to meet patient and carer needs in the immediate, to reduce protracted care and likelihood of re-admission bounce-back in the future.
Information is agency
The study showed the benefits to all of “actively seeking information and asking questions to ensure a thorough understanding of their medical needs and treatment plans” during the discharge and early home transition.
Those who were happiest with the transition process, both patient and carer, said they had achieved autonomy and agency through being “well-informed about their health condition and treatment”, because they had “actively engaged with healthcare providers and asked pertinent questions to ensure clarity and understanding.”
Answers were easier to come by when multiple departments in the hospital setting had clearer channels of communication. Collaboration between departments meant clear information was received by all parties providing care, informing a comprehensive discharge plan and information session for the patient and their caregiver.
Systemic improvements to inter-department communication can mean less missed information, chasing answers for medical staff, as well as soon to be discharged patients and carers.
From understanding what is going on, both patient and carer were able to leverage that to secure more comprehensive and personalized care plans. The informed and collaborative decision-making process transformed the transition from a stressful ‘this is out of my control’ situation to ‘I am the captain of my care journey’, certainly a step up from swabbing the decks. A dignified and strengthened place for seniors and their caregivers.
Communication, Collaboration and Confidence
Beneficial to both the healthcare system, and patients and carers alike, is the comprehensive flow of information between professional teams eventuating in a clear hand-off to the patient and their loved ones in the discharge pipeline.
Through taking the time to clearly, truthfully and humanly provide information about care, why certain measures were taken, why certain medication was better over others, patients and carers were given the dignity in discharge that they were looking for. Equipping patients to comprehend their post-discharge care well provides agency and confidence in themselves, resulting in elevated mood and decreased likelihood of medical decline and hospital re-admission.
Investing in the discharge transition time, while potentially taking more time and resources in the immediate, will have significant resource implications for health systems, medical staff, patients and care-givers in the long-term.
