TRANSFER-I: Hospitalised Older Adults and Their Carers' Perspectives of the Transition Home: A Qualitative Study

Transitioning from hospital to home is a critical and fragmented process for acutely ill older adults and their carers. Despite widespread recognition of its importance, persistent gaps leave older adults vulnerable, highlighting the urgent need for safer transitions in care. Qualitative exploration into end-user experiences of this transition can help to identify gaps in care and inform the development of targeted, person-centred interventions.

To explore the experiences of hospitalised older adults and their carers when they transition from hospital to home.

Participants were purposively sampled during their contact with the rehabilitation and aged care service of a metropolitan hospital. Patients who had transitioned or were in the process of transitioning from hospital to home and informal carers to such patients were eligible. Verbatim transcripts were uploaded into NVivo and analysed using thematic analysis.

A total of 19 separate interviews were conducted, 12 patient and 7 carer interviews. The patients' mean age was 79 years (range 70-88 years), and carers' mean age was 74 years (range 58-85 years). Qualitative analysis developed three main themes during the transition from hospital to home, including (1) Impacting identity and the journey home: independence, frailty and functional ability; (2) Navigating inpatient care, communication and a harmonised transition; and (3) Pillars of support and the reality of social isolation.

Complex challenges were highlighted for hospitalised older adults and their carers during transitions from hospital to home, reinforcing the urgent need for holistic, patient-centred care. This study highlighted the compounding need to tailor discharge processes to individuals and calls for health services to embed patient-centred discharge communication into service provision. These are essential steps towards enhancing the quality and safety of transitional care.