Elucidating the information exchange during interfacility care transitions: Insights from a Qualitative Study

To explore the perceptions of patients, their caregivers and healthcare professionals associated with the exchange of information during transitioning from two acute care hospitals to one rehabilitation hospital.

An exploratory qualitative study using semi-structured interviews and observation.

Patients over the age of 65 years admitted to an orthopaedic unit for a non-elective admission, their caregivers and healthcare professionals involved in their care. Participating sites included orthopaedic inpatient units from two acute care teaching hospitals and one orthopaedic unit at a rehabilitation hospital in an urban setting.

Three distinct themes emerged from participants' narrative of their transitional care experience: (1) having no clue what the care plan is, (2) being told and notified about the plan and (3) experiencing challenges absorbing information. Participating patients and their caregivers reported not being engaged in an active discussion with healthcare professionals about their care transition plan. Several healthcare professionals described withholding information within the plan until they themselves were clear about the transition outcomes.

This study highlights the need to increase efforts to ensure that effective information exchanges occur during transition from acute care hospital to rehabilitation settings.