A rural perspective on home care communication about elderly patients after hospital discharge

Little is known about home health agencies (HHA) and their integration in the continuum of care in rural areas. The aims of this study are to describe the amount and type of patient-related data transferred by discharging hospitals to rural HHAs and to explore the influence of selected organizational factors on that communication process using a previously tested model of inter-organizational communication. In this study, 446 closed-case, elderly patient records at three rural HHAs were reviewed using the Referral Data Inventory. Rural HHAs receive about half of the literature-recommended referral data, characterized primarily by background data, some medical data, and almost no psychosocial or nursing-care data. Referrals transmitted by telephone and written data were superior to referrals transferred by a telephone call only. Hospital affiliated HHAs received significantly greater amounts and richer types of referral data than did free-standing HHAs. Findings suggest that cost-saving measures in the referral process need investigation.