Systems Barriers to Medication Management During Hospital to Home Transitions of Older Adults With Dementia

The hospital-to-home transition is a high-risk period for medication errors and adverse events for older adults living with dementia. Researchers conducted a qualitative study using semi-structured interviews and participant solicited diaries. Caregivers of adults ages 55 and older were recruited to understand barriers to medication management during hospital to skilled home health care transitions. We used a human factors engineering approach to guide our understanding of systems level barriers. At least two researchers independently coded each transcript using content analysis and the ATLAS.ti software. We interviewed 23 caregivers and identified five barrier types stemming from systems breakdowns related to: (1) knowledge and information, (2) access to and use of resources and tools, (3) caregiver burden, (4) pandemic concerns, and (5) health limitations. Caregivers grappled with receiving overwhelming, insufficient, incorrect, or conflicting information, and had difficulty managing information from different sources. Latinx caregivers encountered language barriers that impeded role and task clarity. Caregivers expressed mistrust in health systems elements and inability to access resources. Caregivers were in need of additional caregiving assistance, financial aid, and tools to manage medications. Balancing multiple medications and responsibilities left caregivers burdened. The health limitations of the older adult and COVID-19 concerns related to reduced access to resources and ability to deliver and receive in person care complicated task management. Altogether these barriers reflect systems level breakdowns impeding task understanding, execution, and overall management. These findings will inform the development of interdisciplinary strategies to ensure safer care transitions.

Improving mental health care transitions through information capture during admission to inpatient mental health services: a quality improvement study

Background Many interventions aim to improve the transition from ward to community at the time of discharge, with varying success. Guidelines suggest that discharge planning should begin at admission, but in reality this is ideal rather than standard practice. We aimed to develop a novel information capture tool during admission that facilitates and accelerates discharge. Methods A quality improvement study to develop, implement and evaluate a novel tool that improves information capture upon admission to acute mental health wards within a single English National Health Service (NHS) trust. We developed the tool by synthesising existing evidence and working with multi-agency and multi-disciplinary professionals in two co-design workshops. During implementation the tool was piloted on three wards. Ethnographic observations (145 h) and interviews (45) were used to evaluate the implementation of the tool across the three wards. Thematic synthesis was used to consolidate the findings. Results The tool developed considerably as the process evolved. The finished product is a list of 10 information categories that should be captured from external agencies upon admission to hospital to facilitate discharge planning to community settings. Reported advantages of the tool were: (1) facilitating confidence in junior staff to legitimately question the suitability of a patient for an acute ward (2) collecting and storing essential information in a single accessible place that can be used throughout the care pathway and (3) collecting information from the services/agencies to which patients will eventually be discharged. Conclusions Improving the quality of information at admission has the potential to facilitate and accelerate discharge. The novel tool provides a framework for capturing this information that can be incorporated into existing information systems. However, the introduction of the tool exacerbated complex, fragile distributed team dynamics, highlighting the importance of sociocultural context in information flow transitional interventions within distributed teams.

Health care transitions for persons living with dementia and their caregivers

Background Persons with dementia are likely to require care from various health care providers in multiple care settings, necessitating navigation through an often-fragmented care system. This study aimed to create a better understanding of care transition experiences from the perspectives of persons living with dementia and their caregivers in Ontario, Canada, through the development of a theoretical framework. Methods Constructivist grounded theory guided the study. Seventeen individual caregiver interviews, and 12 dyad interviews including persons with dementia and their caregivers, were recorded and transcribed verbatim. The data were coded using NVivo 10 software; analysis occurred iteratively until saturation was reached. Results A theoretical framework outlining the context, processes, and influencing factors of care transitions was developed and refined. Gaining an in-depth understanding of the complex care transitions of individuals with dementia and their caregivers is an important step in improving the quality of care and life for this population. Conclusion The framework developed in this study provides a focal point for efforts to improve the health care transitions of persons living with dementia.