Performance-Shaping Factors Affecting Older Adults' Hospital-to-Home Transition Success

A Systems Approach

Nicole E. Werner, Ph.D.; Michelle Tong, B.S.; Amy Borkenhagen, M.S.; Richard J. Holden, Ph.D.

Gerontologist. 2019;59(2):303-314.

Abstract and Introduction

Abstract

Background and Objectives: Facilitating older adults' successful hospital-to-home transitions remains a persistent challenge. To address this challenge, we applied a systems lens to identify and understand the performance-shaping factors (PSFs) related older adults' hospital-to-home transition success.

Research Design and Methods: This study was a secondary analysis of semi-structured interviews from older adults (N = 31) recently discharged from a hospital and their informal caregivers (N = 13). We used a Human Factors Engineering approach to guide qualitative thematic analysis to develop four themes concerning the system conditions shaping hospital-to-home transition success.

Results: The four themes concerning PSFs were: (a) the hospital-to-home transition was a complex multiphase process—the process unfolded over several months and required substantial, persistent investment/effort; (b) there were unmet needs for specialized tools—information and resources provided at hospital discharge were not aligned with requirements for transition success; (c) alignment of self-care routines with transition needs—pre-hospitalization routines could be supportive/disruptive and could deteriorate/be re-established; and (d) changing levels of work demand and capacity during the transition—demand often exceeded capacity leading to work overload.

Discussion and Implications: Our findings highlight that the transition is not an episodic event, but rather a longitudinal process extending beyond the days just after hospital discharge. Transition interventions to improve older adults' hospital-to-home transitions need to account for this complex multiphase process. Future interventions must be developed to support older adults and informal caregivers in navigating the establishment and re-establishment of routines and managing work demands and capacity during the transition process.

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Table 1. Older adults' demographic characteristics
Older adult characteristic	N = 31
Age in years (mean; range)	72.61; 65–86
Gender (Female %)	52
Race/ethnicity (%)
African American	13
Caucasian	87
Years of school (%)
12 Years	39
13—16 Years	45
>16 Years	16
Years with congestive heart failure (%)
1 or less	26
2 to 5	26
5 to 10	16
10 to 20	13
20+	6
Number of medications (mean; range)	17 (9–29)

Table 2. Examples Illustrating Alignment or Misalignment Between Prehospitalization Routines and Hospital-to-Home Transition Needs
Alignment between prehospitalization routine and hospital-to-home transition needs	Misalignment between prehospitalization routine and hospital-to-home transition needs
Healthy dietary habits	High-sodium dietary habits
"And I took care of her and so for years and years I worked, but I would always cook the night before and leave things, the veggies and the fruits for her to have. And so we just lived on, that way, proper nutrition." (81 y/o White Female)	"I've always liked my Worcestershire sauce [high in sodium] in my vegetable soup and then on my g reen beans, cause bubba like it in his, so I've just always done that it's just a habit it just made 'em taste better so I just do it." (70 y/o White Male)
Low fluid intake habits	High fluid intake habits
"Well you know I don't really drink. I may drink a bottle of water, but, uh, that's about it." (68 y/o White Female)	"I suppose limiting fluids is the-the toughest cause I was a water drinker; I drank a bottle of water every hour." (83 y/o White Female)
High physical activity habits	Low physical activity habits
"I've always exercised always. For years. You know I used to play ball when I was young cause I'm 70 now, so I'm not young, but I played ball, used to do yoga and uh and I've always been an exercise nut and my-my family always said I was a health nut." (69 year-old Black Female)	"I've gotten myself into such a, uh, a stalemate you might say of, you know, just sittin' in a chair and that's basically where my life has been for years, is just there in that chair." (65 y/o White Male)

Table 3. Example Barriers to Constructing or Reconstructing Self-Care Routines During Hospital-to-Home Transitions, With Illustrative Quotations
Hospital-to-home transition need	Barrier type	Barrier to constructing or reconstructing self-care routine during the hospital-to-home transition and illustrative quotation
Limit sodium intake	Person—individual goals	Eating habits
Limit sodium intake	Person—individual goals	"Nutrition, I haven't heard much of anything about, other than they say stay away from salt and I'll admit my favorite food is Mexican chips and dip. … I don't wanna be totally separated from something I really, really like." (66 y/o White Male)
Limit fluid intake	Organization—communicating needs	Multiple health conditions create conflicts
Limit fluid intake	Organization—communicating needs	"Yeah, they said to limit my uh liquid intake to uh 200 milliliters, does that sound right or 2,000 milliliters? … You know more like the equivalent of a two liter coke … I limit my fluid intake on a daily basis to that and I'm sure I went over … but when you're diabetic you're thirsty too." (66 y/o White Male)
Eat healthy foods such as fresh fruits and vegetables	Environment—community access	Ability to afford healthy foods
Eat healthy foods such as fresh fruits and vegetables	Environment—community access	"I'm not so good on the eating. I, I can't really afford to buy the food the way they want me to, you know, the, uh, salt free and, and, and all of that" (65 y/o White Female)
Exercise regularly	Person—physical ability	Ability to perform exercise
Exercise regularly	Person—physical ability	"He says I need to get out and walk, but I ain't able to walk. I just can't go no more without completely getting out of breath. Yeah, now, I stop and rest when I get out of breath and sit there a few minutes, or stand there, or lean up against something. I sometimes, I'm plum dizzy and I have to hold on to something after I stop, but, uh, some, most of the time, I get to, if I see a place to sit down, that's where I sit down." (76 y/o White Male)
Cook at home instead of eating out	Tools and technology— information availability	Lack of recipes
Cook at home instead of eating out	Tools and technology— information availability	"When uh, when they first uh, when they told me you know that I was going to have to do this and everything, they gave me a site to go on and that's what I said, it was, they, they give you all good information, but they give you very little recipes you know and if they want you to be on this type of diet and all I think they need to get together and get a book and hand it to the person because then I don't think she or he will be overwhelmed like I was" (68 y/o White Female)
Take medication as instructed	Organization—communicating treatment plan	Communication/Comprehension of treatment plan purpose
Take medication as instructed	Person—comprehension of treatment plan	"And they started me off on insulin and, uh, you know, I just, I couldn't understand, I just knew I couldn't see me giving myself four shots a day for the rest of my life, I just, I had no desire to do that." (80 y/o Black Male)

Table 4. Factors Influencing the Capacity of Older Adults in the Hospital-to-Home Transition Period
Factor type	Specific factor influencing capacity and illustrative quotation
Other "work" demands	Responsible for taking care of others
Other "work" demands	"Well I should have gone [to the doctor] sooner. And my wife's physical condition is… anything but good…If it had been easy to get, uh, get someone to be with her, I would have probably gone in sooner, yeah." (83 y/o White Male)
Multimorbidity	Comorbid conditions
Multimorbidity	"You straighten the kidneys out, the heart messes up. You straighten the heart out, the kidneys mess up. You got to-- And then I'm diabetic too, so." (68 y/o White Female)
Health literacy	Ability to understand health information
Health literacy	"I'm taking my Lasix. I mean why am I actually accumulating this, why am I accumulating this fluid. And, uh, the answer is did I drink a lot of water, I said yes, well they said well don't drink, don't drink over two liters a day. Two liters? I'm not going to drink no two liters no day." (67 y/o Black Female)
Illness history	Length of illness
Illness history	"I have a spiritual foundation that supports me, but I've given up, I mean haven't given up on that, but on all the other stuff I've given up. I just can't fight anymore." (68 y/o White Male)
Mental health	Emotional and psychological state
Mental health	"It has caused me more anxiety than anything I've had before."(67 y/o White Female)
Social support	Informal caregiver social support
Social support	"I've noticed that people really don't wanna come over that much you know and since this happened and uh that's been hard." (65 y/o White Female)
Socioeconomic status	Ability to afford paid help
Socioeconomic status	"I'm just exhausted. It's only been 3 or 4 months.(I: What do you, what do you think would change that?) Fulltime housekeeper. (I: A fulltime housekeeper would help that. Does your insurance or anything?) There's absolutely nothing, nothing."
Location	Distance from caregiver
Location	"She'll come, if she know I ain't feeling good, she will come, but she got 30 miles to come, uh, we were classmates, but we're good friends too."

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Performance-Shaping Factors Affecting Older Adults' Hospital-to-Home Transition Success

A Systems Approach

Abstract and Introduction

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