Performance-Shaping Factors Affecting Older Adults' Hospital-to-Home Transition Success: A Systems Approach

Background and Objectives Facilitating older adults' successful hospital-to-home transitions remains a persistent challenge. To address this challenge, we applied a systems lens to identify and understand the performance-shaping factors (PSFs) related older adults' hospital-to-home transition success. Research Design and Methods This study was a secondary analysis of semi-structured interviews from older adults (N = 31) recently discharged from a hospital and their informal caregivers (N = 13). We used a Human Factors Engineering approach to guide qualitative thematic analysis to develop four themes concerning the system conditions shaping hospital-to-home transition success. Results The four themes concerning PSFs were: (a) the hospital-to-home transition was a complex multiphase processthe process unfolded over several months and required substantial, persistent investment/effort; (b) there were unmet needs for specialized toolsinformation and resources provided at hospital discharge were not aligned with requirements for transition success; (c) alignment of self-care routines with transition needspre-hospitalization routines could be supportive/disruptive and could deteriorate/be re-established; and (d) changing levels of work demand and capacity during the transitiondemand often exceeded capacity leading to work overload. Discussion and Implications Our findings highlight that the transition is not an episodic event, but rather a longitudinal process extending beyond the days just after hospital discharge. Transition interventions to improve older adults' hospital-to-home transitions need to account for this complex multiphase process. Future interventions must be developed to support older adults and informal caregivers in navigating the establishment and re-establishment of routines and managing work demands and capacity during the transition process.