Abstract
Objective: To clarify patient/family support and multidisciplinary collaboration by nurses during the
transition from outpatient care to home care for patients who have difficulty coming to the hospital.
Methods: Semi-structured interviews were conducted with nurses at outpatient care and discharge planning department. The data obtained were recorded verbatim, and analyzed qualitatively inductively into codes, subcategories, and categories.
Results: Six categories were extracted from nine participants: （1）grasp with life changes associated with the progression of the disease and support continued outpatient care, （2）supporting patient and family decision-making through dialogue for the introduction of home care, （3）consult with community care professional regarding the introduction of home care and make adjustment to continue home care, （4）coordinate support system in consideration of patient/family anxiety about leaving the hospital, （5）person in charge of coordination office at home care and hospital serve as a bridge during the transitional care, and （6）share information among supporters at hospital and home care to ensure consistency in support goals.
Conclusion: In collaboration among physicians, person in charge of coordination office at home care and hospital played an important bridge role during the transitional care. Outpatient and discharge planning nurses supported decision-making by interacting with patients and their families to address their wavering and anxious about changing primary physicians.
