Older patients’ experiences during care transition

Figures & data

Table 1 Background data of participants, n=14

Patient	Age (years)	Cause for admission to hospital	Care transition
Female	87	Unknown to the patienta	Home – hospital – home
Female	89	Unknown to the patientb	Home – hospital – nursing home – home
Female	87	Fall	Home – hospital – home
Male	88	Fall	Home – hospital – home
Female	89	Fall	Home – hospital – home
Male	86	Only the primary diagnosis known to the patientc	Home – hospital – rehabilitation at the nursing home – hospital – nursing home – home
Female	94	Infection	Home – hospital – home
Female	81	Paralyzed bowel	Home – hospital – home
Female	84	Wrong medication	Service apartment – hospital – service apartment
Female	92	Cancer	Service apartment – hospital – service apartment – hospital – service apartment
Male	87	Infection	Home – hospital – home
Female	90	Stroke	Service apartment – hospital – nursing home
Male	91	Stroke	Home – hospital – home
Male	88	Pneumonia	Home – hospital – home

Notes:

a Reduced general condition,

b fall,

c complications following elective surgery, pneumonia, heart attack, and reduced general condition.

Table 2 Examples of the abstraction process of the content analysis, n=14

Category	Subtheme	Theme
Was asked to participate in discharge meeting	Formal and informal participation in planning the care transition	Participation depends on being invited to planning the care transition
Was asked their opinion about future care needs
The family helped in planning the care transition	Partial participation in planning the care transition
Don’t remember being asked to participate in planning the care transition	No participation in planning the care transition
Was not asked to participate in planning care transition
Information from hospital to home-care staff and patient	Communication during care transition takes place on different levels	Managing continuity in care represents a complex and challenging process
Experiences with written documentation
Communication from patient to health care staff
Unresolved responsibility	Responsibility during care transition varies
Handing over the responsibility
Obliged responsibility
Personal responsibility

Table 3 Examples of abstraction process of participation when planning the care transition, n=14

Theme	Category	Subtheme	Condensed meaning unit
Participation depends on being invited to planning the care transition	Was asked to participate in discharge meeting	Formal and informal participation in planning the care transition	There is supposed to be a final meeting here before I go home. The staff will recommend the home services that I will need when I am discharged. And if we want something we can let them know tomorrow at the meeting.
	Was asked their opinion about future care needs		I could have home care for as long as I felt I needed it, and it has not ended yet.
			I think I was asked several questions about my needs of care when I was discharged.
	The family helped in planning the care transition	Partial participation in planning the care transition	I wasn’t asked if I wanted to be discharged home to my apartment when I was at the hospital. I believe it was my daughters who applied for the nursing home.
			With me, they only discussed more general stuff, but I said that I have my wife at home, and she can help me with almost everything.
	Don’t remember being asked to participate in planning the care transition	No participation in planning the care transition	I can’t remember that I was asked in hospital about what help I would need at home after discharge. I told them that I was alone. And all the aids were already in my apartment when I arrived at home.
			I was probably asked about my home situation at the hospital, but I don’t remember now. And I don’t remember my answer either.
	Was not asked to participate in planning care transition		I knew there was no reason for me to stay there any longer. I can’t remember being asked about the discharge and home care.
			I don’t remember that I was asked directly about what I wanted, but they didn’t do anything against my will.

Table 4 Examples of abstraction process of patient experiences during care transition, n=14

Theme	Category	Subtheme	Condensed meaning unit
Managing continuity in care represents a complex and challenging process	Information from hospital to home-care staff and patient	Communication during care transition takes place on different levels	Yes, they had contact, so everything worked just fine. The hospital told the municipal home care, who said that they would come in the evening.
			At the same time as we came home, we called the nurse from home care who took the papers I was given at the hospital. They had called from hospital as well, but I don’t know what they said.
	Experiences with written documentation		Someone gave me a piece of paper and, I suppose, no […] I guess I should just keep it. I don’t think I should even deliver it.
			I don’t receive enough help. I have a letter from the municipal home-care service, but I can’t sign that I am satisfied with their services. I’ll just leave it until they send a reminder, and then I get to tell them what I think about the aid they are not providing.
	Communication from patient to health care staff		I’ve been receiving a new kind of tablet since I was in hospital. I don’t know if it is because of directions from the hospital, I just take them and keep quiet.
			If I need more help, I just contact the home-care office because I can get more help if needed.
	Unresolved responsibility	Responsibility during care transition varies	There is a nurse from home care saying that she is my primary contact. I didn’t catch her name, but that doesn’t matter. Then, I at least know that someone is responsible for me.
			I don’t know if I am taking too much medicine because there is no one in charge of that now. I believe I have to go to my general practitioner to give a blood sample, but nobody has told me to do that.
	Handing over the responsibility		He (his son) has taken care of it all from the beginning. He called the Municipal Decision Office and made sure that they came from the municipal health care.
			A safety alarm has been applied for, but it is a long wait. This was applied for when I was still in hospital.
	Obliged responsibility		And then I thought I should call the municipal home care and check with them. I think that gradually I will be able to manage on my own.
			You don’t open the book of law to read all these paragraphs. And you don’t go to the municipal home-care office either to ask what it means. So, I don’t think many people would make a complaint about the resolutions. This is simply just a waste of paper.
	Personal responsibilities		I started to use a walking stick today, and I stopped using the walker. I will start to exercise. You know, I got tired really fast, but I can’t give up.
			In the hospital, the physiotherapist gave me an exercise description, and I have used it all by myself as much as I have been able to. So, my condition has improved a lot, from sitting in a wheelchair to using a walking stick.

short-legendSupplementary material 1 Interview guide