College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia.
Adjunct Research Professor, Australian Centre for Christianity and Culture, Charles Sturt University, Barton, Australian Capital Territory, Australia.
J Clin Nurs. 2023 Aug;32(15-16):4599-4613. doi: 10.1111/jocn.16492. Epub 2022 Aug 16.
To reduce the likelihood of preventable readmissions, the aim was to investigate how older people (with their family members) managed their chronic health conditions at home following hospital discharge. The objectives explored older people and their family members' perspectives on how discharge plans assisted self-management of their chronic conditions, their recognition of deterioration and when to seek treatment/re-attend hospital.
Chronic conditions have challenged older adults' self-management, particularly after hospital discharge and can impact on preventable readmission. Few studies have examined patients' and their family members' perspectives on the management of their conditions at home after hospitalisation.
A qualitative exploratory design known as Interpretive Description was utilised.
Purposeful sampling involved 27 community-dwelling older adults; nineteen were discharged patients with one or more chronic health conditions. Eight nominated family members were also recruited to enhance understanding of the older persons' self-management at home. Interviews were undertaken and thematic data analysis followed the COREQ guidelines.
Five themes emerged: (1) Post-Discharge Advice; (2) Managing at Home; (3) Recognition and Response to Deterioration; (4) Community Care and Support; and (5) The "Burden" on Others of Post-Discharge Care.
Older people sought a clear plan for self-management at home prior to discharge. This plan should contain potential signs of deterioration and guidance on future action. We found that support given to older people from family and friends was critical to prevent readmission. In addition, their local General Practitioner and Pharmacist played an essential part in the support of their care. For some, social support services were also important. Nurse telephone follow-up in the week following discharge was mostly absent. However, this strategy would be strongly recommended.
To mitigate against preventable readmission, we recommend the above strategies to assist the older person at home with self-management of their chronic conditions.
为了降低可预防再入院的可能性，本研究旨在调查老年人（及其家庭成员）在出院后如何在家管理其慢性健康状况。本研究的目的是探讨老年人及其家庭成员对出院计划如何帮助他们自我管理慢性疾病的看法，他们对病情恶化的认识以及何时寻求治疗/再次住院。
慢性疾病对老年人的自我管理提出了挑战，尤其是在出院后，这可能会导致可预防的再入院。很少有研究探讨过患者及其家庭成员对住院后在家管理病情的看法。
采用了一种名为解释性描述的定性探索性设计。
目的抽样包括 27 名居住在社区的老年人；19 名是患有一种或多种慢性健康状况的出院患者。还招募了 8 名指定的家庭成员，以增强对老年人在家自我管理的理解。进行了访谈，并按照 COREQ 指南进行了主题数据分析。
出现了五个主题：（1）出院后建议；（2）在家管理；（3）对恶化的识别和反应；（4）社区护理和支持；（5）出院后护理给他人带来的“负担”。
老年人在出院前寻求明确的在家自我管理计划。该计划应包含潜在恶化的迹象和未来行动的指导。我们发现，家人和朋友给予老年人的支持对防止再入院至关重要。此外，他们当地的全科医生和药剂师在支持他们的护理方面发挥了重要作用。对一些人来说，社会支持服务也很重要。护士在出院后的一周内进行电话随访大多是缺失的，但这一策略将被强烈推荐。
为了降低可预防再入院的风险，我们建议采用上述策略来帮助老年人在家中自我管理慢性疾病。
