Ongoing work of older adults at home after hospitalization

This paper describes the hospital-to-home transition process as experienced by elderly people with a medical diagnosis of congestive heart failure. Qualitative data were collected in semi-structured interviews with a sample of 25 older adults within 2 weeks following discharge. Constant comparative data analysis procedures were used. The findings suggest that at 2 weeks post-hospitalization the situation could be described as tentative. The core variable for this study was conceptualized as "a tentative situation', characterized by three key processes: ups and downs associated with managing the illness, caregiver issues, and quality of life challenges. These elders were in need of a post-hospital plan which provided them with ongoing information, additional resources and supportive assistance. To emphasize the changing, uncertain nature of this chronic illness, and the necessity of the health care team developing an ongoing plan of care with the client and family, the trajectory was graphed using the trajectory phasing scheme as described by Corbin & Strauss. The changing nature of congestive heart failure in these participants noted as well as the need for a continuum of care.