Essential Information for Transition of Care for Frail Elderly Patients in Japan: A Qualitative Study
Abstract Background: Information exchange between hospitals and primary care physicians is suboptimal. Most physicians are dissatisfied with the current referral process, and poor communication leads to negative care transition outcomes.Methods: To identify the key information needed in referral letters for successful transition of care. We conducted a qualitative study using consecutive, semi-structured in-person interviews and focus group sessions. We recruited 5 participants for individual interviews and 16 participants for focus groups. All participants were engaged in clinical work. We analyzed all data using qualitative thematic analysis. Interview transcripts were analyzed inductively and reflectively. All results were returned to the participants and modified based on their feedback. Results: The five individual interviews provided a general picture of the current referral process and a useful interview guide for the following focus group sessions. The focus group discussions were used to identify the essential care transition information needed at admission and discharge from the hospital. Essential information on hospital admission were: 1) Basic medical and care information, 2) Care resources available at home, 3) The purpose of admission and the goals of care during hospitalization, and 4) Status of advance care planning (ACP) and patient’s will in an emergency. Essential information on hospital discharge were: 1) Clinical course, 2) Explanation of medical condition during hospitalization, 3) Status of ACP and patient’s will in an emergency, and 4) Medical procedures to be continued at home. Conclusion: We identified the essential information needed for successful transition of care in Japan, particularly on admission to and discharge from acute hospitals. The clinical effectiveness of a template that contains the information identified in our study warrants investigation.