Experiences of Older Adults Living with Frailty Transitioning from Hospital to Home - A Qualitative Descriptive Study

Abstract

The transition from hospital to home within Ontario's healthcare system presents significant challenges for older adults living with frailty, highlighting gaps in current transitional care practices. The Ontario Health Team (OHT) model guided this study, which aimed to understand the experiences of older adults living with frailty aged 65 and older, along with their key health partners (i.e., individuals and institutions involved in their direct and indirect care), during their transition from hospital to home in Ontario. Utilizing a qualitative methodology and drawing on the input from semi-structured focus groups, the study captured diverse views of the transition process, highlighting its challenges and facilitators. The study participants included 18 older adults with frailty, 11 family caregivers, 15 healthcare professionals, and 14 administrators. Thematic analysis of the data revealed key themes, providing insights into the physical and emotional complexities of care transitions for older adults living with frailty. The key themes are: 1) healthcare is more than just physical care—it is holistic care; 2) there is therapeutic value in familiar surroundings; 3) a voice, a choice, and a purpose are essential for patients and caregivers; 4) the disconnect between hospital and community is challenging to navigate; 5) informal caregivers need more significant support to continue in their role; and 6) income, language, and equity impact care. The study's findings outlined previously undocumented gaps in current transitional care practices in Ontario, such as communication failures, resource scarcity, and systematic barriers in institutional settings. Evidence from the study suggests that integrating the holistic needs of older adults and their key health partners is crucial for enhancing patient outcomes. This research, therefore, contributes to a more profound understanding of care transition for older adults living with frailty in Ontario from a multi-disciplinary and multi-participant perspective, offering valuable insights for healthcare policy and practice development.