Older adults with multiple chronic conditions typically have more complex care needs that require multiple transitions between healthcare settings. Poor care transitions often lead to fragmentation in care, decreased quality of care, and increased adverse events. Emerging research recommends the strong need to engage patients and families to improve the quality of their care. However, there are gaps in evidence on the most effective approaches for fully engaging patients/clients and families in their transitional care. The purpose of this study was to engage older adults with multiple chronic conditions and their family members in the detailed exploration of their experiences during transitions across health care settings and identify potential areas for future interventions.
This was a qualitative study using participatory visual narrative methods informed by a socio-ecological perspective. Narrated photo walkabouts were conducted with older adults and family members (n = 4 older adults alone, n = 3 family members alone, and n = 2 older adult/family member together) between February and September 2016. The data analysis of the transcripts consisted of an iterative process until consensus on the coding and analysis was reached.
A common emerging theme was that older adults and their family members identified the importance of active involvement in managing their own care transitions. Other themes included positive experiences during care transitions; accessing community services and resources; as well as challenges with follow-up care. Participants also felt a lack of meaningful engagement during discharge planning, and they also identified the presence of systemic barriers in care transitions.
The results contribute to our understanding that person- and family-centered care transitions should focus on the need for active involvement of older adults and their families in managing care transitions. Based on the results, three areas for improvement specific to older adults managing chronic conditions during care transitions emerged: strengthening support for person- and family-centered care, engaging older adults and families in their care transitions, and providing better support and resources.