Understanding transitions of care in older adults with hip fractures: A qualitative multiple-case study in Ontario

Abstract

Introduction: Transitions in care between and within healthcare sectors are a major focus across health jurisdictions. It is a time of vulnerability for both patients and their families. Hip fractures are one of the leading causes of hospitalizations among the older population, with patients averaging 3.5 care setting transitions before reaching their final destination. Thus, hip fracture patients are an ideal population to study for understanding transitions of care for older adults. These patients have high rates of readmissions due to medical complications within 6 months of being discharged from acute care. Of those patients who survive one-year post-injury, only 40% can perform activities of daily living independently, leading to potential social vulnerability. Across health regions, there is substantial variation in system performance on care relating to hip fractures, which requires further understanding of the contextual factors influencing care transitions, patient/informal care experiences, and health and well-being outcomes. Methods: A multiple-case study design was chosen to compare transitions in care for hip fractures in two contrasting health jurisdictions. Regions were selected for variation in patient populations, system performance and geography. Qualitative interviews were conducted with patients, their informal care providers (e.g. family/friends), clinicians and decision-makers in both jurisdictions. When possible, patients and caregivers were followed through their care journey by sequential interviews. By interviewing a variety of key stakeholders, the intention was to develop a holistic understanding of care transitions for complex patients and system-level factors contributing to this journey. Results: Data collection is ongoing. We anticipate interviewing 56 individuals (16 patients, 16 family members, 12 clinicians and 12 decision-makers). Preliminary results suggest three main themes: 1) patient, caregiver and healthcare provider uncertainty; 2) urgency to improve transitions; and 3) transitions as a component of the larger care experience. Discussion: Consequences of poor transitions include delays, adverse medication events, dissatisfaction among patients and families as well as high patient readmission rates and emergency department visits following acute care discharge. Findings from this work will identify context specific solutions at the individual, community and system levels to optimize transitions for patients with hip fractures and for those that provide care. Conclusion (w/ key findings): Barriers and enabling factors that influence optimal care transitions are specific to local health system contexts; however, the experiences of key stakeholders across the two jurisdictions were remarkably similar. There remains much room for improvement in care transitions for complex patient populations and their caregivers. Lessons Learned: A community-engagement and integrated knowledge translation approach takes effort and time, but ensures the research is of value to key system users. Limitations: This study compares only two health care jurisdictions in Ontario, with interviewees recruited primarily from one hospital in each jurisdiction, and interviews conducted in English and French alone. It is possible that experiences with transitions may be different across different health regions, in different hospitals in the study regions, and among non-English or French speaking participants. Suggestions for Future Research: Future research can expand to different health regions and include patients and caregivers who speak different languages.

Keywords

• care transitions
• hip fractures
• complex patients
• older adults
• care journey