Errors during care transitions of older adults are common, costly and sometimes lethal. A care transition is defined as the movement of a person from one health care setting to another and is commonly associated with adverse outcomes. The aging of the population is leading to greater reliance on care delivered in the home, the most common and poorly understood health care delivery setting. For unclear reasons, those who require skilled home health care (SHHC) services (e.g., home nursing) after hospital discharge are among those at highest risk of experiencing hospital readmission. Strategies tailored to the complexity of the hospital/SHHC transition are needed to ensure safe transitions, yet there is relatively little research to guide improvement efforts.
This is a multisite, mixed-methods study. The study's ultimate goal is to use a human factors engineering approach to develop an index to be used by SHHC agencies in real time to identify and reduce potential risks to older adults’ safety during hospital/SHHC transitions.