Transitions and Translations: Health System Integration for Older Adults

Abstract

Introduction: Following a hip fracture, older patients typically undergo transitions through several health care settings during the course of their recovery. The quality and continuity of care is challenged by the involvement of multiple health professionals across many care settings, frequent transitions in care, and interactions between formal and informal care networks. Methods: The "InfoRehab" project investigated informational and transitional care needs of older hip fracture patients, in rural and urban Canadian locations. An ethnographic approach (including ~200 interviews) was used to understand the perceived need, use, and exchange of health information for older patients across multiple health care setting transitions, from the perspectives of patients, families and health care providers. Results: Care transitions were challenged by inadequate information sharing, missing or unnecessary documentation, and limited communication. Benefit was observed in situations where patients or caregivers had a good prior understanding of the health system. The results point to needs for supports for health system navigation, improved inter-professional collaboration, more efficient and effective use of health information systems, and greater patient and family engagement. Conclusions: We are currently working to translate these findings into practice and policy to foster greater continuity of care and health system integration for older adults. [ABSTRACT FROM AUTHOR]