Abstract
BACKGROUND: Transitioning from hospital to home is challenging for many older people living with chronic health conditions. Transitional care facilitates safe and timely transfer of patients between levels of care and across care settings and includes communication between practitioners, assessment and planning, preparation, medication reconciliation, follow-up care and self-management education. To date, there is limited understanding of how to actively involve care recipient service users in transitional care. OBJECTIVE: This study was part of a larger research project. The objective of this article was to report the first study phase, in which we aimed to describe user experience pertaining to patients and carers. DESIGN, SETTING AND PARTICIPANTS: The study design was qualitative descriptive using interviews. Patients (n = 19) and carers (n = 7) participated in semi-structured interviews about their experience of transition from hospital to home in an urban Australian health-care setting. Interview data were analysed using thematic analysis. FINDINGS: All participants reported that they needed to become independent in transition. Participants perceived a range of social processes supported their independence at home: supportive relationships with carers, caring relationships with health-care practitioners, seeking information, discussing and negotiating the transitional care plan and learning to self-care. DISCUSSION: Findings contribute to our understanding that quality transitional care should focus on patients' need to regain independence. Social processes supporting the capacities of patients and carers should be emphasized in future initiatives. CONCLUSION: Future transitional care interventions should emphasize strategies to enable negotiation for suitable supports and assist care recipients to overcome barriers identified in this study.