The lived experience of the hospital discharge “plan”: A longitudinal qualitative study of complex patients
BACKGROUND
Transitions in care are a high-risk time for patients. Complex patients account for the largest proportion of healthcare costs but experience lower quality and discontinuity of care. The experiences of complex patients can be used to identify gaps in hospital discharge practices and design interventions to improve outcomes.
METHODS
We used a case study approach with serial interviews and chart abstraction to explore the hospital discharge and transition experience over 6 weeks. Participants were recruited from a small hospital in Toronto that provides care to complex patients living with human immunodeficiency virus (HIV). Framework analysis was used to compare data across time-points and sources.
RESULTS
Data were collected from 9 cases. Participants presented with complex medical and psychosocial challenges, including substance use (n = 9), mental health diagnoses (n = 8) and a mean of 5 medical comorbidities in addition to HIV. Data were analyzed and reported in 4 key themes: 1) social support; 2) discharge process and transition experience; 3) post-discharge follow-up; and 4) patient priorities. After hospital discharge, the complexity of participants’ lives resulted in a change in priorities and subsequent divergence from the discharge plan. Despite the comprehensive discharge plans, with referrals designed to support their health and activities of daily living, participants experienced challenges with social support and referral uptake, resulting in a loss of stability achieved while in hospital.
CONCLUSION
Further investigation and changes in practice are necessary to ensure that discharge plans for complex patients are realistic within the context of their lives outside of the hospital. Journal of Hospital Medicine 2017;12:5-10. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Patient complexity is associated with greater hospital readmission rates,1,2 poorer quality of care,3 and lower patient satisfaction.4 Improving outcomes for complex patients is a global priority,5 and local initiatives such as Ontario’s Health Links are being developed, yet evidence to inform care is lacking.6-8
The prevalence of patients living with multiple comorbidities is increasing as advances in medicine enable people to live and manage chronic diseases.9-11 However, these medical gains have resulted in an increased burden on both patients and healthcare systems. Socioeconomic status and co-occurring psychosocial challenges further complicate health and healthcare in marginalized populations.12,13
Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is one example of a disease that medicine has transformed. Individuals living with HIV today, on antiretroviral medications, may be able to manage their chronic illness for decades.14,15 However, in addition to social determinants of health that influence ongoing adherence and engagement in care, these medications do not completely eradicate the impact of HIV and, as a result, HIV-positive individuals are at a greater risk of developing additional comorbidities.15 People living with HIV may, therefore, represent an important patient population in which healthcare interventions and system improvements for complex patients should be explored.
Improving health systems and better supporting complex patients requires a broader understanding of the patient experience and the challenges encountered, especially during high-risk periods such as hospital discharge. Qualitative research approaches are designed to help us understand social phenomena in their “natural” settings,16 and thus suited to achieve this goal, providing critical insight to inform healthcare systems and policies.17,18 This study sought to answer the question, “What are the obstacles and challenges faced by complex patients during hospital discharge and post-discharge transition?” We approached patient complexity holistically, using a unified Complexity Framework6 that connects 5 health dimensions—social capital, mental health, demographics, health and social experiences, and physical health—identified as important to understanding complex patients and their interaction with healthcare. A longitudinal case study approach was used, with multiple sources of data, to understand the clinical context and discharge plans in relation to the lived experience of patients over time, exploring potential misalignment and areas for improvement.
METHODS
This community-based research study was conducted at Casey House, a 13-bed subacute care hospital in Toronto, Canada that provides in-patient and community programs to a complex patient group. All patients are HIV-positive. Inpatient hospital care is provided by an interdisciplinary team, including physicians, social workers, nurses, and healthcare aides. A harm reduction approach is taken to substance use. Twelve beds are for general admission. Patients may be transferred from acute-care hospitals or referred by community-based providers. One bed is reserved for scheduled 2-week respite stays.
