The five in-person interviews provided a general picture of the current referral process and a useful interview guide for the following FG sessions. Briefly, all participants admitted that they experienced problems in care transition, and all agreed to develop a template with the necessary information for admission to and discharge from hospital for frail elderly patients, especially home-bound elderly patients with multiple care needs. All participants agreed that a different set of information is needed for care transition on admission compared to discharge. We present these results separately below.
1) Essential information on hospital admission
Basic medical and care information
Participants remarked that basic medical and care information is crucial. Examples of such information are the patient’s or a family member’s contact information and the patient’s past medical history, current activities of daily living (ADL), and medication history. Most of this information is generally already provided in referral letters, but a template may be useful and would improve the ease with which health care staff can find such information.
One participant said,
“I think past medical history, medication, and family information or ADL of patients are usually written in referral letters. But we are very grateful when all this information is listed in one place.” (physician, acute hospital)
Care information is also very important.
“We have a database containing all of the care users’ information…and based on that, we can provide basic care information for home care, but we are weaker in (collecting) medical information. For example, ADL is usually not listed in such a database, so we need to send this information to the admitted hospital separately. So, if it's an emergency admission, we will usually send a referral later when the hospital needs it.”(care manager, community comprehensive care center)
Care resources available at home
The participants also identified details related to care resources, housing, and key family members for decision making as important information for admission.
“… It is really great when (the letter) contains details about care resources and decision-making capacity, especially regarding resuscitation. And information on the key people in the family is really, really important.” (physician, acute hospital).
“Regarding the contents (of the referral letter), we actually don’t need the clinical information in that much detail. Instead, some primary care physicians note the key people for the patient and their understanding of the patient’s current status. I really appreciate that.” (nurse, acute hospital)
Purpose of admission and care goals of hospitalization
Participants of the FGs suggested that the purpose and goal of hospitalization must be written in the referral letter. Further, participants from the community remarked that the information should include procedures that can be performed at home to enable them to easily assess the care/treatment goals during hospitalization.
“For example, the referral letter from the home-care team should contain information about the expected goal of the treatment.” (nurse, community)
“For example, when the family does not want the patient to receive curative treatment, but just wants pain relief. It is rare, but we really appreciate it when we read a letter that includes a statement saying that the home-care team can provide such palliative care at the patient’s home. It is great.” (physician, acute hospital)
Status of advance care planning (ACP) and patient’s will in an emergency
Many participants, especially those from acute hospitals, discussed the importance of details related to the status of ACP. For patients who have already discussed their preference for care at the end of life, this information should be provided as top priority. However, most of the time such information is missing from the referral letter.
One physician at an acute hospital said,
“If the patient had discussed advance care planning details while at home, and the referral letter includes that information, I think the treatment for rehabilitation may differ. Most referral letters do not include (such information).” (physician, acute hospital)
Another community physician said,
“As a physician providing home-visit care, I always emphasize continuity at care transition. Most of the patients that I am seeing now are unable to visit the hospital or are patients with terminal cancer. So, I think I need to pay attention to what the patient wants to do for the rest of his/her life. So, I would like to transfer such information (to the hospital), including the kind of care they want to receive and the kind of care they do NOT want to receive.” (physician, community)
2) Essential information on hospital discharge
Participants expressed that a summary of the patient’s clinical course is essential, including medications, past medical history, test findings, and procedures received during hospitalization. In particular, information about changes in medication is often lacking. Additionally, despite being very important for the care transition process, information on ADL and the patient’s cognitive status during hospitalization is often missing.
“(Medication information), for both internal and external medicine, is often missing. If a patient is hospitalized in the internal medicine ward, we sometimes think it is unnecessary to write the name of the patient’s eye drops in the hospital chart.” (physician, acute hospital)
“For example, diet, toileting, consciousness, physical restraint, paralysis, speech, wounds… if a patient is discharged to the care facility in xx community, we always write all of these details down (in the letter).” (physician, acute hospital)
Explanation of medical condition during hospitalization
FGs with community staff in particular explored the need to provide an explanation of patients’ medical condition during hospitalization.
“Yes, definitely we would like to know how the physician in the hospital explained his/her medical condition. Often, it is simply one sentence, like ‘he or she improved, so he/she can return home.’ ... But, if that's all they heard, the description depends on what they heard about how their condition improved at all. I always want to ask about that to confirm the patient’s will in the future.” (nurse, community)
“An additional important column, as I mentioned earlier, containing a description of the disease, prognosis, informed consent, and so on. I'd like the doctor to write a letter that includes all of this information.” (physician, acute hospital)
Status of ACP and patient’s will in an emergency
If APC was processed during hospitalization, such information should be provided to staff in the community after discharge.
“Even though the prognosis of cancer or COPD is determined using a framework of the terminal stage of the disease, there are still family members who call an ambulance (after discharge), because of the pain the patient is experiencing. Even in such cases, we can contact them as soon as the prognosis has been determined (in the hospital)….” (physician, acute hospital)Medical procedures to be continued at home
Participants in the community in particular indicated the importance of providing information about necessary medical treatment or procedures to be continued at home, the details of these procedures, how the patient and caregivers are taught, and the level of patient/caregivers’ understanding.
“Nutrition, such as diet, is particularly important. And medical treatment that directly affects life is also important. And to what extent the patient or caregiver can provide this information is critical, I think. But this is difficult to discern from only documents.” (nurse, community)
Strengths and weaknesses of smooth information transfer
FG participants discussed the strengths of smooth information transfer using a referral template. From the health care staffs’ perspective, using a template will have a positive impact on the continuity of care, reduce information duplication, and enhance care efficiency. It may also improve quality of care, such as safety and patient satisfaction.
“It is not about only hospital or only home care… but basically, both physicians and nurses together provide care and share the goal together…” (physician, acute hospital)
“… Maybe this will be the merit for patients and families. We don’t need to repeat the same story again and again… that is definitely a merit (everybody agrees)” (physician, community)
“And, with regards to ‘a conflict’, it may reduce conflict between doctors, between patients and doctors. It also saves time” (physician, acute hospital)
Format of the referral letter
The participants of the FGs agreed that a set format for information transfer is necessary and useful but had different opinions on the actual format.
“It seems like it will be easy to write the letter if clinical and other information are separated, and we can write freely. If we have lots to write, such as the profile of the patient’s family, and the letter is named ‘clinical information referral letter’ (Shinryo-joho-teikyo-syo), it may be difficult to write such information… So, maybe the letter itself should be renamed; for instance, ‘Family member information letter’ or ‘Supplement letter’, etc. If the name is different… then we can write whatever we want, as much as necessary.” (physician, acute hospital)
“If we have a common tool to help us write the letter, it would be appreciated. And I hope it will be possible to exchange letters with a common format. And if we could send it online, it would be even better.” (nurse, community)