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. 2014 May 12:14:e012.
doi: 10.5334/ijic.1525. eCollection 2014 Apr.

Breakdown in informational continuity of care during hospitalization of older home-living patients: a case study

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Breakdown in informational continuity of care during hospitalization of older home-living patients: a case study

Rose Mari Olsen et al. Int J Integr Care. .

Abstract

Introduction: The successful transfer of an older patient between health care organizations requires open communication between them that details relevant and necessary information about the patient's health status and individual needs. The objective of this study was to identify and describe the process and content of the patient information exchange between nurses in home care and hospital during hospitalization of older home-living patients.

Methods: A multiple case study design was used. Using observations, qualitative interviews and document reviews, the total patient information exchange during each patient's episode of hospitalization (n = 9), from day of admission to return home, was captured.

Results: Information exchange mainly occurred at discharge, including a discharge note sent from hospital to home care, and telephone reports from hospital nurse to home care nurse, and meetings between hospital nurse and patient coordinator from the municipal purchaser unit. No information was provided from the home care nurses to the hospital nurses at admission. Incompleteness in the content of both written and verbal information was found. Information regarding physical care was more frequently reported than other caring dimensions. Descriptions of the patients' subjective experiences were almost absent and occurred only in the verbal communication.

Conclusions: The gap in the information flow, as well as incompleteness in the content of written and verbal information exchanged, constitutes a challenge to the continuity of care for hospitalized home-living patients. In order to ensure appropriate nursing follow-up care, we emphasize the need for nurses to improve the information flow, as well as to use a more comprehensive approach to older patients, and that this must be reflected in the verbal and written information exchange.

Keywords: home care; hospitalization; nursing information exchange; older people; transfer.

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Figures

Figure 1.
Figure 1.
Overview of data collection and analysis, exemplified by Case 1.
Figure 2.
Figure 2.
Overview of patient pathway and process of information exchange between home care nurses and hospital nurses.
Figure 3.
Figure 3.
Cases with statements in conformity with VIPS keywords identified in written and verbal communication.

References

    1. Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging with multimorbidity: a systematic review of the literature. Ageing Research Reviews. 2011;10(4):430–9. - PubMed
    1. Nardi R, Scanelli G, Corrao S, Iori I, Mathieu G, Cataldi Amatrian R. Co-morbidity does not reflect complexity in internal medicine patients. European Journal of Internal Medicine. 2007;18(5):359–68. - PubMed
    1. Condelius A, Edberg AK, Jakobsson U, Hallberg IR. Hospital admissions among people 65+ related to multimorbidity, municipal and outpatient care. Archives of Gerontology and Geriatrics. 2008;46(1):41–55. - PubMed
    1. Vogeli C, Shields AE, Lee TA, Gibson TB, Marder WD, Weiss KB, et al. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. Journal of General Internal Medicine. 2007;22(Suppl 3):391–5. - PMC - PubMed
    1. Reed J, Cook G, Childs S, McCormack B. A literature review to explore integrated care for older people. International Journal of Integrated Care [serial online] 2005 May 14;5 [cited 2013 Feb 1]. Available from: URN:NBN:NL:UI:10-1-100361. - PMC - PubMed

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