How to Implement Transitional Care in France: first lesson

Abstract

Introduction: Gaps in continuity of care may happen at hospital discharge, especially in elderly patients. Patients arriving at home have difficulty to manage themselves the care that was driven by the hospital team. It is well known that transitional care interventions can reduce hospital readmissions. Though, they are poorly developed in France. Objectives: Our project was to tailor and implement transitional care in an Acute Geriatric Department of a French University Hospital. Our approach is based on patient and/or caregiver empowerment to allow self-managed care. This pilot study evaluated the interest of a coaching intervention. Method: A transitional care manager met patients returning home, for a 20 minutes semistructured interview. He asked about information they have and remaining questions, encouraging them to ask the hospital team. A follow-up phone call was made 3 weeks after. We report here quantitative data obtained in the interviews and qualitative analysis of the implementation of this procedure. Results: We included 250 patients in 2 years (mean age 84), who represent half of home discharge. The semi-structured interviews show that only 40% of the patients knew the changes made in their usual medication, and one third knew that they have to contact their general practitioner. At follow-up calls, 23% reported a change in medications after discharge, 29% needed advices, 38% have not seen their general practitioner yet. We elaborate an information form to support medical discharge meeting, and propose after one year a mandatory training for junior medical staff on transitional care; these interventions did not change the results. Implementations barriers will be discussed. Conclusion: A coaching approach is not sufficient in the context of a French University hospital, as patients don't currently get enough information to allow empowerment. A more global person centered care approach with nurse care managers promoting patient activation via teamwork is currently designed.