Poor Older Persons’ Transitional Care: Health Care Provider, Informal Care Provider and Patient

Perspectives
Introduction to the Problem
Older adults suffer from high morbidity and therefore have higher demands for health
care. Generally, they require care from multiple professionals, across a variety of care settings.
Despite the high demand for care among elderly people, care systems in the US can only provide
acute and episodic care. Transition of care in this age group between community care providers,
social care providers and health services providers is highly frequent, which further increases the
risk of adverse social and health outcomes. It is estimated that more than 80% of newly
hospitalized older adults will experience at least 6 transitions annually. Most of the adverse
events and health outcomes result from poor transition practices, as well as, poor coordination of
services between care providers. Poor transition services disempower the elderly resulting in
dissatisfaction with services and stress.
Transitional care involves a large number of both informal and formal caregivers, as well
as, other professionals, who share responsibility for caring for an individual patient. Over time,
the team that is responsible for the care becomes diverse and complex. Such complexity results
in communication breakdown, poor coordination and discontinuity of care. Although several
reasons for such problems, including poor communication have been studied, there are several
gaps as to how such factors affect care transition in other settings such as between professional
care providers and specialists. The key reason is that a significant portion of the current literature
focuses on transition of care among the elderly from hospitals to home settings, and therefore
fails to consider impediments within the hospital or other specialist care settings. Therefore, the
aim of the proposed study is to investigate the continuum of care coordination for elderly people,
from the perspectives of those who are involved with the primarily purpose of understanding
what leads to poor care coordination during transition, either to different levels or to home
settings.
Significance of the Problem to Nursing
Poor transition care for the elderly is a significant problem in the country. One of the
most important consequence of poor transition care is high preventable readmission rates.
Around 2.6 million seniors are readmitted within the first month, while one in five elderly people
are readmitted within 3 months of discharge. The annual cost of such readmissions is around 26
billion annually. While these estimates are estimations, there is sufficient data on whether such
readmissions are preventable. Around 27% of such readmissions are preventable. In addition to
readmissions, poor transition care can lead to medication errors. The Medicare Payment
Advisory Commission estimates that more than 1.5 million people suffer negative health
outcomes as a result of medication errors, -a problem that costs the nation around 3.5 billion
dollars. A majority of these errors (66%) occur during transition of care, including discharge,
transfer and admission.
Additional costs arise as a result of poor coordination. Some of these arise from provision
of medication for preventable diseases, repetition testing, as well as, duplicative visits to
different care givers, especially when the roles of care providers within the continuum of care is
not well demarcated. The overall result is that financial strain on patient increases, their health
suffers and the workload among care providers increase. To address these problems and increase
the effectiveness of care, I proposed this study to examine factors that interplay across multiple
settings through the eyes of those involved in the process, with the aim of understanding reasons
for poor transition despite the development of multiple models to deal with the issue.
Purpose Statement
Transitioning an elderly patient from one setting to another or one level to another is a
period of vulnerability for elderly persons. Inappropriate and poor transition mechanisms
disempower the elderly, leading to poor economic, health and social outcomes. The health
effects of mismanaged transitions including increase cost of health, high morbidity and high
mortality. The purpose of the proposed study is to evaluate the process of transition among the
elderly, from the perspectives of care givers in multiple settings to further identify the key
reasons for continued poor transition. Unlike existing studies, the study will focus on informal
care givers, professional care givers and the patients who are at the center of the transition
process. Information from the study will allow one to bridge the gap on the various roles played
by the three groups participating in the care process and steps that can be taken to improve the
process.
Research Aim
The aim of the proposed study is to investigate care coordination during transition among
the elderly from multiple perspectives, including health care providers, informal care providers
and patients to determine the core factors that lead to ineffective care during transition from one
setting to another. The following research questions will guide the proposed study project:
1. What are the common factors that impede the success and effectiveness of
transition of care among the elderly from the perspectives of patients, care
providers and informal care providers who participate in the process.
2. What characterizes transition care of the elderly, including follow up and why
does performance of transition care vary?
3. What are the major obstacles to collaboration and coordination of care between
health services providers, informal care givers and patients, as reported by those
who participate in the process?
Master’s Essentials That Align with the Project
The proposed project aligns with several essentials of master’s education in nursing. The
first and most important is Essential VII, that is related to improving and promoting coordination
and collaboration during care. A master’s prepared nurses must recognize their membership in
intra-professional teams and must therefore work towards proper coordination with other
professionals, through communication, collaboration and coordination. In this spirit, the
proposed study seeks to examine care coordination in transition care, to allow nurses to identify
factors that impede or promote intra and extra-professional collaboration. By understanding the
dynamics of care coordination from the perspectives of stakeholders involved in the transition
care of the elderly, this project will further the knowledge of the writer on care coordination and
collaboration in nursing transition care, as well as, others who participate in this field. The other
important essential is essential IX, which requires master level nurses to understand that nursing
practice revolves around interventions that can improve health across the health care provision
continuum. Given that this project focuses on impediments to transition care involving the
elderly, understanding them will improve one’s ability to meet the requirements of this essential.
Literature Review
The literature on care transitions among the elderly is not new, and multiple scholars
have studied care transition and the adverse events that are associated with the process. One of
the earliest studies was by Forster et al (2003), a classic study that found that over 20% of all
hospital discharges (hospital to home) resulted in some form of negative health outcome. Some
of these adverse events include medication, follow-up, social and health care errors, incomplete
assessment, failure to detect infections and increased risk of falls among the elderly. Follow up
research by Kannan et al (2013) paints a grimmer picture and found that at least one in five
discharges involved some form of adverse event, despite the fact that over a third of these events
are ameliorable or preventable. Despite the vast size of literature in this field, transition remains
poor, begging the question as to why such literature combined with multiple models of
improving transition of care has failed to improve the overall effectiveness of transition care.
Multiple scholars have studied reasons why the transitional care is associated with high
levels of adverse events. In their qualitative study, Rustad et al., (2016) examined the
experiences of elderly patients. Semi-structured interviews involving 14 patients were conducted
to capture the views of the elderly. The researchers identified two key themes, one participation
in the transition care was dependent on invitation despite being the patients and second, the
transition process was too complex and challenging for those involved. These themes reflect the
findings of Laugaland (2015) who noted that patient characteristics, care setting characteristics
and clinician characteristics were among the major reasons as to why transition care was
challenging. Other factors that have been cited as impediments to effective transition care
include poor communication (main factor), poor coordination and lack of awareness on the roles
of those involved in the transition process.
Despite the existence of multiple factors, the literature has predominantly focused on the
role of communication as a major impediment to effective outcomes. Studies by the scholars
such as Toscan Mairs, Hinton, And Stolee (2012), Glenny et al (2013), Eliot (2014), as well as,
Allen, Ottomann and Roberts (2012) indicate the central role played by poor communication in
impeding proper transition. These scholars conclude that proper communication on worker roles,
as well as, information on care reduces the risk of readmission, and enhances health outcomes,
which consequently enhance the transition process and the effectiveness of the process. It is no
wonder that the World Health Organization has emphasized that effective flow of information
and communication is vital to effective care transition. Consequently, the literature has focused
on understanding and improving communication, through multiple models and interventions.
However, current evidence is fragmented and inconclusive, and any progress towards identifying
the underlying causes has been scant.
While the literature is vast, the majority of studies focus on isolated aspects of transition
care, making it difficult to understand the problems that impede the effectiveness of the process.
Studies on transition of patients to home settings mostly comprise studies of risk associated with
process and single isolated aspects of the process, such as information transfer, communication,
discharge planning, medication reconciliation, and medication errors. The most prominent theme
has been communication and information transfer. By extending the focus of study, it is possible
to further knowledge on why performance of transition care among elderly varies. The key
reason is that transition care involves complex teams who operate in a variety of environments,
governed by different rules. Studies on the interplay between these factors and how they
influence each other is rather scant.
One of the recent studies to study the complexities of transition care involving the elderly
was Robinson et al (2012). In the study, Robinson and colleagues found that the success of any
transition process was dependent on multiple factors, including timeliness, proper
communication, positive relationships, geriatric knowledge and the relationship between the care
provider and the patient. These findings are supported by the work of Storm et al (2104), who
noted found that there are multiple factors that are interplay in the process of transition. In the
study, Storm and colleagues were able to identify several challenges that impeded transition
process. These include: (a) patient assessment (clinical assessment, patient history, current
condition), (b) context (handover numbers, contest, stability of environment, rules), (c)
communication (electronic, oral, written), (d) patient characteristics (disease, health condition,
security, satisfaction), (e) healthcare personnel competence (communication, skills,
collaboration, role awareness) and, (f) kin involvement (either as informal care givers or through
advocacy and support). The findings by Storm et al (2014) further support the notion that the
transition process is highly complex and requires a multi-faceted approach. Yet, even in the face
of the informative nature of the findings of Storm et al (2014) his focus, like those of other
scholars are on the discharge process.
The complexity of transition care process, over emphasis of role of communication in existing
studies, as well, as failure of existing studies to collect information on impediments across levels
of care and setting gives the impetus required to conduct this study. This study applies a multi-
faceted approach to collect data from multiple stakeholders at different settings with the aim of
evaluating and determining factors that influence the quality of transition care. By applying this
approach, the study will allow nurses to appreciate the complex interplay of factors in the
transition process that ultimately determine the success of the process. The proposed study
provides a new approach to the understanding of transition care among the elderly.