Identifying unmet needs of older adults transitioning from home health care to independence at home: A qualitative study.

• Transitions from HHC to independence or caregiver-supported care at home is a critical period of elevated risk that must be addressed to help patients achieve their health care goals after discharge. • In this study, we identified gaps and omissions in HHC care practices that contributed to unmet patient and caregiver needs during transitions from HHC to independence at home. • Findings suggest that components of transitional care models, such as a focus on continuity of care, may be important modifications in usual HHC practice with potential to improve patient and caregiver outcomes. Health care practices to prepare older adults and their family caregivers for transitions from home health care (HHC) to independence at home are rarely studied. The objective of this multiple case study was to describe HHC patient and clinician perceptions of unmet needs after HHC discharge and recommendations to address them in future research. In this qualitative study, data were collected using chart-reviews and semi-structured interviews with paired patients (or caregivers as proxy) and HHC clinicians (N=17 pairs). We identified three themes: (1) low patient and caregiver engagement in care planning increased risk for preventable health events after HHC discharge, (2) limited continuity of care restricted patient and caregiver access to community-based services, and (3) gaps in patient and caregiver education influenced independent care of chronic illnesses after discharge. Findings suggest opportunities to improve care practices to prepare older adults and their caregivers for transitions from HHC to independence at home. [ABSTRACT FROM AUTHOR]