A focus group interview with health professionals: establishing efficient transition care plan for older adult patients in Korea

As the older population with complex care needs with multiple acute and/or chronic diseases is growing, it is inevitable to have a disproportionately higher rate of hospitalization experience for older adults than the younger population. In older patients, functional care needs commonly coexist on top of multimorbidity, and their functional status dynamically interacts with underlying illness leading to adverse effects by hospitalization [1]. Therefore, the transitional care plan is critical to ensure patients are discharged from the hospital to an appropriate place to improve clinical and functional outcomes [2]. Previous studies showed that strategic discharge planning and transitional care interventions had made evident short-term reductions in readmissions of older patients at risk and improved health outcomes [3‐5]. Given that the Korean society reached the aging society, [6] and admissions to various healthcare levels increase over time, acquiring insights for care transition of the complex older population is essential.

Despite long-term care insurance (LTCI) mostly covers for home care and includes financial benefits for older adults in Korea who have chronic illnesses or disabilities, [7] many older adults are transferred to institutions such as rehabilitation hospitals, convalescent hospitals, or nursing homes, rather than discharged to their homes. The post-discharge period is often fragmented, and some patients miss out on golden time to recover their functional status through rehabilitation, putting a significant burden on the caregivers [8]. Current LTCI requires at least 6 months to operate the eligibility selection process. Therefore, older patients who were not in the insurance plan before hospitalization are challenged to receive the benefits as soon as they are discharged. The transitional care plan may play an essential role in matching optimal institutions to meet patient's specific care needs across medical, functional, and social domains. However, decisions on care transition are commonly deemed as a responsibility of patients and their family members, and largely performed in an ad-hoc manner, to date in Korea [9]. These unmet needs in care transitions may contribute to newly acquired disabilities and disability after hospitalization that is highly prevalent after inpatient care due to acute illness [10, 11].

The objective of this study is to explore barriers to meeting the needs of discharge planning for older adults in Korea. More specifically, by interviewing professionals working at tertiary hospitals in Seoul, Korea, we anticipated discovering barriers to transition care plans for inpatients with complex care needs and establishing effective solutions for the process. We also aimed to address specific concept which has to be built on our understanding of the current practice in the fields.

Despite advancements in medical treatments in Korea, management of older patients after discharge remains fragmented without specific transitional care plan. To improve the continuity of care of older patients, comprehensive understanding of current barriers through objective discussions were crucial. In this study, we found that barriers to establishing transition care planning in hospitalized patients with complex care needs can be largely classified into 2 domains: patient and institutional. We also recognized that these barriers might be alleviated by effective communication strategies and patient-centered care models accounting for functional and medical issues [15]. These findings contrast with previous government-driven care transition models that primarily focus on medical resources and hospital networks rather than patient-centric issues impeding effective transitional care.

The fragmentation in the transitional care process derives from the setting of disease-centered practiced culture since there was no defined universal approach. Lack of communication comes from treatment-focused and careless attitudes towards what would essentially matter to the patient. For patient-centered approaches, we may adopt frameworks of the Age-Friendly Health Systems initiative that led by The John A. Hartford Foundation and the Institute for Healthcare Improvement in partnership with the American Hospital Association and the Catholic health Association of the United States [16]. The goal of the system is to making U.S. health care systems age-friendly across all care settings through implementation of the 4 Ms framework: What matters; Medications; Mobility; and Mentation [16, 17]. The concept values the extent to what really matters to the older adult and their families, unlikely to widespread disease-centered healthcare system. Traditional provider-driven approach cannot facilitate unprecedented population ageing wherein complex and interrelated needs are detected. By embracing the patient-centered care and successfully implemented the 4Ms, many health systems in the U.S improved patient satisfaction, family engagement, length of stay and readmissions [15]. This being said, Age-Friendly health care is little known and practiced in Korea compared to its rapid spread of the framework in the U.S. hospitals and medical practices. Through an active adoption of patient-centered care with 4Ms framework, traditional provider-driven approaches in Korea can be mitigated and bring a more sophisticated stepwise transition to a long-term care for older patients.

From the discussions in our study, we were able to address information transfer deficits between hospitals were another common barrier to effective transitional care. This does not apply only to older patients but also to general patients. In addition, patients’ misperceptions of healthcare across the primary care system and low chance of being referred to tertiary hospitals escalate the level of anxiety in patients after being discharged from tertiary care hospitals. It is crucial to recognize Korea's current care delivery system to understand this problem. Although healthcare coverage in Korea had achieved almost nationwide as of today, [18] the role of primary care is not yet identified, and patients are lacking with their key case managers [19]. Patients in Korea can choose any type of outpatient hospital clinic simply without having referrals from primary care physicians, even to hospital-level institutions for their first visit [19, 20]. This creates a competitive relationship between hospitals, rather than being cooperative. Because of the unique system, patients prefer larger hospitals over small clinics in the community for primary care [21, 22]. Under this circumstance, primary care has been devalued in Korea and failed to establish a sustained primary care physician(PCP) and a patient relationship that prolongs patients’ overall medical concerns over time and events in between [23]. It is often the patient’s role to communicate one’s medical concern with hospitals through medical documents, and therefore it carries communication hardship. One study applied PCP-Enhanced Discharge Communication Intervention which decreased post-discharge medication discrepancies [24] indicating the importance of PCP involvement in the hospital discharge process as patient-centered case managers [25]. Older patients at high risk of hospitalization or otherwise in need of complex treatments can ensure continuity of care by providing close follow-up with the PCP in the primary care setting. In addition, this guarantee of continuity of care can alleviate communication difficulties and sharing of medical information between hospitals [25, 26].

Following discharge for older adults after an acute illness in tertiary institutions, many older adults who have difficulties in activities of daily living are transferred to LTCH, which is a unique form of long-term care (LTC) in Korea [7]. LTCHs are widespread in Korea. Still, its role has not been distinguished from nursing homes unlike its first intention, where the major priority was functional rehabilitation to return them home with greater independencies [27]. A study by Kim et al. concluded that the current LTC system in Korea should be redesigned as a person-centered delivery through integrated assessment system; therefore the service can address both health and social care needs [28]. Other studies showed that functional decline that is associated with hospitalization is highly prevalent in older adults and recovery of function is critically important [29‐31]. Rehabilitation centers in Korea are likely to have specific priorities to specific neurological or orthopedic insults, not a functional deconditioning related to general medical events, with specific fee structures for indicated conditions. Therefore, rehabilitation facilities usually cannot accept patients with disabilities due to frailty or deconditioning after acute illness. Even though the Pilot Project of Rehabilitation Medical Institutions was started in 2020 to resolve this gap, only 45 institutes have participated the program to date. Therefore, many patients with mixed medical and functional requirements are frequently transferred to LTCH, while the provision of optimal subacute care and rehabilitation is highly unlikely due to the current daily fixed fee scheme. Similarly, under the DRG fee structure, appropriate subacute care for patients from tertiary hospitals was unrealistic due to economic losses. In our study, participants urged that patient-centric fee structure in peri-transition care situations is imperative to resolve barriers to transferring complex patients from tertiary hospitals and may also help alleviate current ‘patients’ inclination’ toward large centers.

Concern over the healthcare silo effect and poor cooperation between institutions has been growing, leading physicians in practice difficult to position patients at appropriate places. Physicians in the study noted that hospitals receiving older patient transfers in the community must be transparent to what extent they can manage patients. Another significant factor is deficits in information between hospitals. Discharge summaries and discharge letters often miss substantial and essential patient information [32] few data is passed over for the healthcare continuum. Previous studies found that proposed discharge date and destination collection from patients with interdisciplinary collaboration teams, raised the perceptions of patients’ awareness of discharge plans, prevented unnecessary delays in discharge, and provided physicians about alternative destinations regarding older patients’ preferences [33]. Another aspect to consider in Korea, is to utilize nursing communication. Discharge summaries in Korea are written by medical doctors yet nursing or other professional’s comments are not included. However, multidisciplinary professionals are involved in providing patient care during the hospitalization, particularly nurses are the closest staff members who could suggest persistence of problems and difficulties especially for older adult’s future care. Implementing multidisciplinary components in discharge summaries; including nursing, physical therapy, and social worker for post-discharge care plan would improve breakdown in communication [34, 35].

Our study has several limitations. This is qualitative study and only included physicians from upper-level healthcare hospitals, or academically affiliated in urban area. The population may not be generalizable to other settings. However, we identified a wide range of barriers consistent with smaller institutions and discussed the issues that are related to primary care settings. Also, ongoing qualitative and quantitative studies with the involvement of multidisciplinary professionals would potentially address this limitation. Second, there was only one focus group for our study. Multiple focus group interviews may have helped to reach adequate saturation of the data. Furthermore, it would have been interesting to look at how the patients or caregivers’ perspectives differ from healthcare professionals in transition care planning. As yet, there is no study conducted to evaluate barriers on a particular topic in Korea. Therefore, the study is unique and has several strengths. Interviewing acute healthcare professionals who are in part of the decision making for the discharge planning may have allowed us to better understand what causes disruptions continuity of care for patients. Second, the qualitative research data could give detailed and rich real-world information about what has been experienced from each participant that were able to reveal the complexities what is being studied. Further research is needed on health systems considering policies that supports the topic with interventions.

In this study, 12 medical professionals identified barriers to optimal transitional care plans, including patient’s and institutional factors. Older patients face more challenges arising from transitional care fragmentation, given that the complexity of functional care needs is additional. More patient-centered decision-making should be implemented to address current unmet care needs for patient discharge planning. Improved care structures for a peri-transition period may improve medical and functional outcomes after acute hospitalizations.