Transitional Care Management from Emergency Services to Communities: An Action Research Study

Area of Science:

• Nursing
• Gerontology
• Health Services Research

Background:

• Nurses are developing hospital-to-community transition projects.
• Effective transitional care is crucial for elderly patients post-emergency services discharge.

Purpose of the Study:

• To analyze transitional care for elderly individuals (70+) discharged from emergency services back to the community.

Main Methods:

• Action research involving nurses, elderly patients, and caregivers.
• Data collection via interviews, medical records, observation, phone calls, and meetings.
• Qualitative analysis (Bardin's) and statistical treatment (SPSS).

Main Results:

• Only 31.4% experienced care continuity post-discharge.
• 33.4% were readmitted to emergency services within 30 days.
• Identified issues include poor referral data, inter-level communication barriers, lack of policies, and low patient health literacy.

Conclusions:

• Urgent need to improve hospital-to-community care coordination for elderly patients.
• Transitional care planning must address communication, policy, and patient understanding.
• Enhanced support is vital for patients returning home after emergency care.