Perspectives on Transitional Care for Vulnerable Older Patients: A Qualitative Study

Review Article

J Fam Med. 2020; 7(6): 1218.

Perspectives on Transitional Care for Vulnerable Older Patients: A Qualitative Study

Lisa S van T1*, Sanne JK2, Laura CB3, Willemsen G3, Jacobijn G1,3 and Yvonne MD3

¹Department of Public Health and Primary Care, Leiden University Medical Center, The Netherlands

²Department of Socio-Medical Science, Erasmus School of Health Policy and Management, The Netherlands

³Department of Gerontology and Geriatrics, Leiden University Medical Center, The Netherlands

*Corresponding author: Lisa S van Tol, Department of Public Health and Primary Care, Leiden University Medical Center, The Netherlands

Received: September 18, 2020; Accepted: October 13, 2020; Published: October 20, 2020


Background: Transitional care for vulnerable older patients after acute hospitalization back home is increasingly important. Despite previous studies, optimal transitional care of vulnerable older patients remains undefined.

Purpose: This study explores what is needed to satisfy these patients with transitional care, from the perspectives of these patients themselves, informal caregivers and nurses.

Methods: Patients (n=13) and informal caregivers (n=10) were interviewed after hospital discharge. Hospital and home care nurses (n=9) participated in two focus groups. Verbatim transcriptions were analyzed according to the framework method.

Results: Patients (mean age 85.5) and informal caregivers indicated transitional care is optimal if, on top of the organization of this transition, they have trust in the professionals involved. Elements of this organization and trust together stimulated three preferred outcomes of transitional care: the patient going home, the patient reaching adequate health and feeling safe. Nurses indicated no other elements or outcomes.

Conclusion: Transitional care for vulnerable older patients is optimal if, on top of the organization of transitional care, these patients and their informal caregivers have trust in the professionals involved. Regarding the challenge of organizing increasingly complex transitional care for vulnerable older patients, the focus should shift towards optimizing trust.

Keywords: Discharge Planning; Nurse-Patient Relationships; Older Adults; Patient Perspectives; Primary/Secondary Care Interface

Background and Purpose

The population of older persons is growing and the length of hospital stays decreased over the last decades. These trends together cause a rapid increase in the number of older patients experiencing hospital discharge while still being in a vulnerable status [1]. For these patients, rehabilitation for a larger part takes place outside the hospital, under the responsibility of primary care providers [2]. Besides, the proportion of Dutch older persons receiving primary care by home care organizations has increased [3]. Hence, transitional care, the continuity of care between the inpatient hospital care and primary care back home, is increasingly important for vulnerable older patients.

In reaction to these trends, many interventions have been developed to optimize transitional care for vulnerable older patients over the last decades. Among others, interventions were developed that implemented communication between hospital and primary care providers before hospital discharge [4], discharge planning [5], geriatric assessments and post discharge support [6,7] into organizational structures. Many of these interventions aim to reduce length of hospital stays, number of ED visits after discharge or to improve quality of life. Reviews showed that several of these interventions indeed do so [8,9]. However, the underlying mechanism improving these outcomes remained unknown [8].

Accordingly, patients’ experiences with transitional care often remain suboptimal [5,10-12]. Little is still known about what is needed to optimize transitional care from the perspectives of vulnerable older patients [13,14]. Until today the majority of qualitative studies regarding transitional care for vulnerable older patients focused on the perspectives of professional care providers. However, their perspectives are divergent [11,15]. Exploring the perspectives of vulnerable older patients on transitional care and comparing their perspectives to the perspectives of health care providers may help to point further research, health care innovations and policy development on optimizing transitional care in the right direction.

Methods and Procedures


This study has a qualitative design using semi-structured interviews and focus groups. We conducted interviews with vulnerable patients aged 70 years old and over, who were recently discharged after acute hospitalization with an indication for home care, and their informal caregivers. Elements of optimal transitional care were identified from their perspectives. Focus groups were conducted with hospital and home care nurses to explore major differences and similarities between the perspective of these professionals and the perspective of vulnerable older patients and their informal caregivers. The interviews and focus groups were performed between April and November 2017 in the South Holland province of the Netherlands. Participants were recruited from an academic hospital, a regional hospital and several home care organizations.


Vulnerable older patients were selected from the hospitals’ electronic patient files by entitled geriatric and transfer nurses in March 2017. Inclusion criteria were age of 70 years old or over, acute hospitalization and vulnerability during the hospital stay according to the Dutch ‘VMS screening’ that regards age, delirium, falling, malnutrition and physical limitations [16]. Exclusion criteria were terminal illnesses, language barriers and living outside the study area. Eligible patients were contacted by telephone to ask for their participation in an interview at home about their experiences around their hospital discharge, preferably together with one of their informal caregivers. The aim was to recruit approximately fifteen patients to be able to reach data saturation.

To invite hospital and home care nurses for participation in a focus group, an e-mail was sent to care managers of the four largest home care organizations in the area and to the heads of three hospital departments per hospital. The aim was to organize two focus groups in which various home care organizations and the two hospitals would be represented. There were no exclusion criteria.

All participants gave oral and written informed consent before the start of their interview or focus group. The area’s medical ethical committee ‘CME’ did not need to approve upon the study, since the study was not subject to the Dutch Medical Research Involving Human Subjects Act (WMO).

Data Collection

The semi-structured interviews were guided by topic lists. To compose this topic list, we selected questions possibly relevant to vulnerable older patients and their informal caregivers in transitional care from four well known Dutch and European existing questionnaires on continuity of care [17], hospital care [18], preoperative care [19] and general practice care [20], and from a topic list of an earlier qualitative study about elderly persons’ experiences with participation in hospital discharge process [21]. The topic list was checked by members of a regional older person’s advisory board and a pilot interview was performed. The topic list included questions about continuity of care, alignment, information provision, patient participation, interaction with professional care providers, feelings, overall satisfaction, points for improvement and demographic characteristics. All interviews took place at the patients’ homes and were performed by a master student.

For the semi-structured focus groups, a topic list was written as well. The main question of this topic list was ‘What is the ideal transition of care for vulnerable older patients?’. Other questions were about the organization, barriers, improvements, target group, tips and tops of transitional care for vulnerable older patients and demographic characteristics. Focus groups took place in the academic hospital within the study area and were moderated by a junior researcher and observed by a senior researcher. All interviews and focus groups were audio recorded and field notes were made.

Qualitative Analysis

The audio recordings were transcribed verbatim. For familiarization with the data, all audio recordings were listened. Analyses were performed by two researchers according to the framework analysis as described by Green and Thorogood. [22], in Microsoft Office Word and Excel as follows. Based on elements of optimal transitional care identified from openly coding the focus group transcripts and two interview transcripts and from literature, a framework of codes was made. Subsequently, all transcripts were coded with this framework. New codes and sub-codes were added throughout the coding process. Some codes were grouped into plausible elements of transitional care according to the researchers. By re-reading and re-coding, elements were organized into a conceptual model about which consensus was reached between the researchers. Participants’ demographic characteristics were described by making use of IBM SPSS Statistics version 23 descriptive statistics.


Of the selected 25 patients eligible for participation, 6 were excluded because of terminal illness (n=2), language barriers (n=3) or living outside the region (n=1). Of the 19 vulnerable older patients approached, thirteen (68%) agreed upon participation in an interview. All interviews took place seven to thirteen days after hospital discharge and lasted for 25 minutes to one hour. In Table 1 the characteristics of the participants from the interviews and the focus groups are presented. The patients’ mean age was 85.5 years old (SD 1.5, range 77 to 95), 8 of them (61.5%) of them were female and their hospital stay ranged from 3 to 14 days (mean 8.0 days (SD 1.0)). In 10 of the 13 executed interviews, an informal caregiver participated as well. The informal caregivers of two patients had work obligations at the moment of the interview and one patient did not have any informal caregivers. The informal caregivers were spouse (n=3) or offspring (n=7) of the patient. Interviewed patients and informal caregivers graded their satisfaction with the transition of care in a range from 6 to 10 on a 0-10 scale (patients: mean 8.1 (SD: 0.3), informal caregivers: mean 7.8 (SD 0.5)). Data saturation was reached.

Citation:Lisa S van T, Sanne JK, Laura CB, Willemsen G, Jacobijn G and Yvonne MD. Perspectives on Transitional Care for Vulnerable Older Patients: A Qualitative Study. J Fam Med. 2020; 7(6): 1218.