Harrison James D, Fang Margaret C, Sudore Rebecca L, Auerbach Andrew D, Bongiovanni Tasce, Lyndon Audrey
Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA.
Division of Geriatrics, University of California San Francisco, San Francisco, California, USA.
Health Expect. 2025 Jun;28(3):e70248. doi: 10.1111/hex.70248.
Hospital-to-skilled nursing facility (SNF) transitions have been characterised as fragmented and having poor quality. The drivers, or the factors and actions, that directly lead to these poor experiences are not well described. It is essential to understand the drivers of these experiences so that specific improvement targets can be identified. This study aimed to generate a theory of contributing factors that determine patient and caregiver experiences during the transition from the hospital to SNF.
We conducted a grounded theory study on the Medicine Service at an academic medical centre (AMC) and a short-term rehabilitation SNF. We conducted individual in-depth interviews with patients, caregivers and clinicians, as well as ethnographic observations of hospital and SNF care activities. We analysed data using dimensional analysis to create an explanatory matrix that identified prominent dimensions and considered the context, conditions and processes that result in patient and caregiver consequences and experiences.
We completed 41 interviews (15 patients, 5 caregivers and 15 AMC and 6 SNF clinicians) and 40 h of ethnographic observations. 'They were talking to each other, but not to me' was the dimension with the greatest explanatory power regarding patient and caregiver experience. Patients and caregivers consistently felt disconnected from their care teams and lacked sufficient information leading to uncertainty about their SNF admission and plans for recovery. Key conditions driving these outcomes were patient and care team processes, including interdisciplinary team-based care, clinical training and practice norms, pressure to maintain hospital throughput, patient behaviours, the availability and provision of information, and patient's physical and emotional vulnerability. The relationships between conditions and processes were complex, dynamic and, at times, interrelated.
This study has conceptualised the root causes of poor-quality experiences within the hospital-to-SNF care transition. Our theory generation identifies targets for clinical practice improvement, tailored intervention development and medical education innovations.
We partnered with the Hospital Medicine Reengineering Network (HOMERuN) Patient and Family Advisory Council during all stages of this study.
从医院到专业护理机构（SNF）的过渡过程一直被认为是碎片化的，且质量较差。导致这些不良体验的驱动因素，即直接引发这些问题的因素和行为，目前尚未得到充分描述。了解这些体验的驱动因素对于确定具体的改进目标至关重要。本研究旨在构建一种理论，阐述在从医院过渡到SNF期间决定患者和护理人员体验的影响因素。
我们在一家学术医疗中心（AMC）的内科服务部门和一家短期康复SNF开展了一项扎根理论研究。我们对患者、护理人员和临床医生进行了个人深度访谈，并对医院和SNF的护理活动进行了人种学观察。我们使用维度分析来分析数据，以创建一个解释性矩阵，该矩阵确定了突出维度，并考虑了导致患者和护理人员产生相应后果及体验的背景、条件和过程。
我们完成了41次访谈（15名患者、5名护理人员、15名AMC临床医生和6名SNF临床医生）以及40小时的人种学观察。“他们彼此交流，但不与我交流”是对患者和护理人员体验具有最大解释力的维度。患者和护理人员始终感觉与他们的护理团队脱节，并且缺乏足够的信息，这导致他们对入住SNF以及康复计划感到不确定。导致这些结果的关键条件包括患者和护理团队的流程，其中涵盖跨学科团队护理、临床培训和实践规范、维持医院周转量的压力、患者行为、信息的可获取性和提供情况，以及患者的身体和情感脆弱性。条件与流程之间的关系复杂、动态，且有时相互关联。
本研究已将医院到SNF护理过渡期间质量不佳体验的根本原因概念化。我们生成的理论确定了临床实践改进、量身定制干预措施开发和医学教育创新的目标。
在本研究的所有阶段，我们都与医院内科再造网络（HOMERuN）患者及家属咨询委员会合作。
