Integrated transitional care: patient, informal caregiver and health care provider perspectives on care transitions for older persons with hip fracture

Introduction: Complex older adults, such as those with hip fracture, frequently require care from multiple professionals across a variety of settings. Integrated care both between providers and across settings is important to ensure care quality and patient safety. The purpose of this study was to determine the core factors related to poorly integrated care when hip fracture patients transition between care settings. Methods: A qualitative, focused ethnographic approach was used to guide data collection and analysis. Patients, their informal caregivers and health care providers were interviewed and observed at each care transition  A total of 45 individual interviews were conducted. Interview transcripts and field notes were coded and analysed to uncover emerging themes in the data. Results:  Four factors related to poorly integrated transitional care were identified: confusion with communication about care, unclear roles and responsibilities, diluted personal ownership over care, and role strain due to system constraints.  Conclusions: Our research supports a broader notion of collaborative practice that extends beyond specific care settings and includes an appropriate, informed role for patients and informal caregivers. This research can help guide system-level and setting-specific interventions designed to promote high-quality, patient-centred care during care transitions.

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