From Hospital to Home: Assessing the Transitional Care Needs of Vulnerable Seniors

Purpose: This qualitative study assessed the needs of patients and caregivers during the transition from hospital to home. We specifically identified unmet needs of ethnic minorities, recent immigrants, and seniors with limited English proficiency (LEP). Findings are translated into recommendations for improving services to these groups during health care transitions. Design and Methods: This needs assessment included extensive analysis of qualitative data collected from 20 language-, culture-, and ethnic-specific focus groups with caregivers who recently assisted a senior after a hospital discharge. Findings from these focus groups were supplemented by 5 in-depth, longitudinal case studies of recently hospitalized seniors and their caregivers. Results: Inadequate information and training at discharge were themes that spanned all groups, despite ethnicity or language. Additional unmet needs were identified for ethnic minorities, those with LEP, and recent immigrants, including lower levels of social support than might be expected, lack of linguistically appropriate information and services, and cultural and financial barriers to using long-term care services. Implications: As ethnic diversity increases among older Americans, it will become increasingly important to design health care services to meet the needs of diverse groups. Recommendations include assessments of informal care, bilingual information and services, partnerships with community agencies providing culturally competent services, and expansion of home- and community-based services to near-poor seniors.