Continuity and Coordination of Care During Hospital-To-Home Transitions: Healthcare Professionals' Perspectives

Aim: To gain insight into healthcare professionals' perceptions and needs regarding hospital-to-home transitions. Design: Qualitative phenomenological study. Methods: Hospital and primary care professionals participated in focus groups and interviews. Participants were recruited from a Dutch University hospital and from our networks between May and September 2023. Data were analysed using thematic analysis. Results: We conducted seven focus groups and twelve interviews. Three themes emerged: "Collaboration and information exchange between professionals", "Coordination and continuity of care", and "Interaction between professionals, patients, and families". Conclusion: This study suggests that professionals would benefit from clear guidelines and arrangements for communication with colleagues to support care coordination and continuity. Collaboration and information sharing are essential for providing integrated, patient-centred care. Additionally, involving patients and families in decision-making regarding hospital-to-home transitions, in a way that considers their needs, is important for effective care. Implications: This study highlights the importance of clear communication and collaboration between professionals to ensure continuity of care. It emphasises the need for integrated care, where patients and families are actively involved without being overwhelmed. Impact: Transitions from hospital-to-home are often hindered by fragmented, non-individualised care. Improved collaboration, clear coordination, and patient-family involvement can address this. This research can positively impact professionals across different settings, policymakers, and advocacy groups aiming to improve integrated patient-centred care. Patient or Public Contribution: The interview guide was developed with professionals who reviewed it and provided feedback. Professionals provided us with their lived experiences by participating in interviews and focus groups. Reporting Method: This study adhered to the COREQ guidelines. Trial Registration: N.A