2022 Volume 10 Issue 2 Pages 8-19
Purpose：This study aimed to clarify the content of post-discharge transitional care for older patients who were discharged from acute hospitals to their homes.
Method：We conducted semi-structured interviews with eleven Discharge Planning Nurses involved in transitional care at acute hospitals.
Results：We categorized the post-discharge transitional care for patients into two types of actions: assessment and intervention. Next, we identified twenty-one subcategories and seven major categories by analyzing the content of post-discharge transitional care for patients. The seven major categories included “assessment of post-discharge care,” “encouragement for patients to have a vision of their future care based on the reality of post-discharge care,” and “establishment and maintenance of good relationships among patients, families, and care teams.”
Conclusion：Discharge Planning Nurses provided ongoing support and encouragement to various stakeholders in their continued care for the diverse post-discharge needs of older patients. This study will contribute to improving the quality of transitional care by professionals, and it is necessary to consider standardizing the content of post-discharge transitional care and the verification of its effectiveness in the future.
