Despite advancements in medical treatments in Korea, management of older patients after discharge remains fragmented without specific transitional care plan. To improve the continuity of care of older patients, comprehensive understanding of current barriers through objective discussions were crucial. In this study, we found that barriers on establishing transition care planning in hospitalized patients with complex care needs can be largely classified into 2 domains, patient factors and institutional factors. We also recognized that these barriers might be alleviated by effective communication strategies and patient centered care models accounting both functional and medical issues.(11) These findings are in contrast with previous government-driven care transition models that largely focus on medical resources and hospital networks rather than patients’ centric issues impeding effective transitional care.
The fragmentation in transition care process derives from the setting of disease-centered practiced culture since there was no defined universal approach. Lack of communication comes from treatment-focused and careless attitudes towards what would essentially matter to the patient. For patient-centered approaches, we may adopt frameworks of the Age-Friendly Health Systems initiative that led by The John A. Hartford Foundation and the Institute for Healthcare Improvement in partnership with the American Hospital Association and the Catholic health Association of the United States.(12) The goal of the system is to making U.S. health care systems age-friendly across all care settings through implementation of the 4 Ms framework: What matters; Medications; Mobility; and Mentation.(12, 13) The concept values the extent to what really matters to the older adult and their families, unlikely to widespread disease-centered healthcare system. Traditional provider-driven approach cannot facilitate unprecedented population ageing wherein complex and interrelated needs are detected. By embracing the patient-centered care and successfully implemented the 4Ms, many health systems in the U.S improved patient satisfaction, family engagement, length of stay and readmissions.(11) This being said, Age-Friendly health care is little known and practiced in Korea compared to its rapid spread of the framework in the U.S. hospitals and medical practices. Through an active adoption of patient-centered care with 4Ms framework, traditional provider-driven approaches in Korea can be mitigated and bring a more sophisticated stepwise transition to a long-term care for older patients.
From the discussions in our study, we were able to address information transfer deficits between hospitals were another most common barrier to effective transitional care. This does not apply only for older patients, but also in general patients. In addition, patients’ misperceptions of healthcare across the primary care system and low chance of being referred to tertiary hospitals escalates level of anxiety in patients after discharged from tertiary care hospitals. To understand this problem, it is important to recognize current care delivery system in Korea. Although healthcare coverage in Korea had achieved almost nationwide as of today,(14) the role of primary care is not yet identified, and patients are lacking with their key case managers.(15) Patients in Korea can choose any type of outpatient hospital clinics simply without having referrals from primary care physicians, even to hospital-level institutions for their first visit.(15, 16) This creates a competitive relationship between hospitals, rather than to be cooperative and because of the unique system, patients prefer for larger hospitals over small clinics in community for primary care.(17, 18) Under this circumstance, primary care has been devalued in Korea and failed to establish a sustained primary care physician(PCP) and a patient relationship that prolongs patients’ overall medical concerns over time and events in between.(19) It is often patient’s role to communicate one’s medical concern with hospitals through medical documents and therefore it carries communication hardship. One study applied PCP-Enhanced Discharge Communication Intervention which decreased post-discharge medication discrepancies,(20) indicating the importance of PCP involvement in the hospital discharge process as patient centered case managers.(21) Older patients who are at high risk of hospitalization or otherwise in need of complex treatments can ensure continuity of care by providing close follow-up with the PCP in the primary care setting. In addition, this guarantee of continuity of care can alleviate communication difficulties and sharing of medical information between hospitals (21, 22)
Following discharge for older adults after an acute illness in tertiary institutions, many older adults who have difficulties in activities of daily living are transferred to LTCH which is an unique form of long-term care (LTC) in Korea.(23) LTCHs are widespread in Korea but its role has not been distinguished from nursing homes unlike its first intention, where the major priority was functional rehabilitation to return them home with greater independencies.(24) A study by Kim et al. concluded that the current LTC system in Korea should be redesigned as a person-centered delivery through integrated assessment system; therefore the service can address both health and social care needs.(25) Other studies showed that functional decline that is associated with hospitalization is highly prevalent in older adults and recovery of function is critically important. (26–28) Rehabilitation centers in Korea are likely to have specific priorities to specific neurological or orthopedic insults, not a functional deconditioning related to general medical events, with specific fee structures for indicated conditions. Therefore, rehabilitation facilities usually cannot accept patients with disabilities due to frailty or deconditioning after acute illness. Even though the Pilot Project of Rehabilitation Medical Institutions was started in 2020 to resolve this gap, only 45 institutes have participated the program to date. Therefore, many patients with mixed medical and functional requirements are frequently transferred to LTCH, while provision of optimal subacute care and rehabilitation are highly unlikely due to current daily fixed fee scheme. Similarly, under DRG fee structure, appropriate subacute care for patients form tertiary hospitals was unrealistic due to economic losses. In our study, participants urged that patients-centric fee structure in peri-transition care situations are imperative to resolve barriers on transferring complex patients from tertiary hospitals and may also help to alleviate current ‘patients’ inclination’ toward large centers.
Concern over healthcare silo effect and poor cooperation between institutions have been growing, leading physicians in the practice difficult positioning patients at appropriate places. Physicians in the study noted that hospitals receiving older patient transfers in the community must be transparent to what extent they can manage patients. Another significant factor is deficits in information between hospitals. Discharge summaries and discharge letters often miss substantial and essential patient information,(29) few data is passed over for continuum of healthcare. Previous studies found that proposed discharge date and destination collection from patients with interdisciplinary collaboration team, raised the perceptions of patients’ awareness of discharge plans, prevented unnecessary delays in discharge, and provided physicians about alternative destinations regarding older patients’ preferences.(30) Another aspect to consider in Korea, is to utilize nursing communication. Discharge summaries in Korea are written by medical doctors yet nursing or other professional’s comments are not included. However, multidisciplinary professionals are involved in providing patient care during the hospitalization, particularly nurses are the closest staff members who could suggest persistence of problems and difficulties especially for older adult’s future care. Implementing multidisciplinary components in discharge summaries; including nursing, physical therapy, and social worker for post-discharge care plan would improve breakdown in communication.(31, 32)
Our study has several limitations. This is qualitative study and only included physicians from upper-level healthcare hospitals, or academically affiliated in urban area. The population may not be generalizable to other settings. However, we identified a wide range of barriers consistent with smaller institutions. Another limitation is that the study does not contain stories of patients or caregivers. Lack of patient and caregiver representation may have impacted on the study results. Further research is needed on health systems considering policies that supports the topic with interventions.