Identifying Challenges Associated With the Care Transition Workflow From Hospital to Skilled Home Health Care: Perspectives of Home Health Care Agency Providers

Mahiyar Nasarwanji, Nicole E. Werner, Kimberly Carl, Dawn Hohl, Bruce Leff, Ayse P. Gurses, Alicia I. Arbaje

Research output: Contribution to journalArticle

Abstract

Older adults discharged from the hospital to skilled home health care (SHHC) are at high risk for experiencing suboptimal transitions. Using the human factors approach of shadowing and contextual inquiry, we studied the workflow for transitioning older adults from the hospital to SHHC. We created a representative diagram of the hospital to SHHC transition workflow, we examined potential workflow variations, we categorized workflow challenges, and we identified artifacts developed to manage variations and challenges. We identified three overarching challenges to optimal care transitions—information access, coordination, and communication/teamwork. Future investigations could test whether redesigning the transition from hospital to SHHC, based on our findings, improves workflow and care quality.

Original languageEnglish (US)
Pages (from-to)185-203
Number of pages19
JournalHome health care services quarterly
Volume34
Issue number3-4
DOIs
StatePublished - Oct 2 2015

Keywords

  • care transitions
  • communication
  • frail elderly
  • home health care
  • human factors engineering
  • qualitative research
  • teamwork

ASJC Scopus subject areas

  • Health Policy
  • Community and Home Care
  • Public Health, Environmental and Occupational Health

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