Continuity and Coordination of Care During Hospital-To-Home Transitions: Healthcare Professionals' Perspectives.
J W M van Grootel, R J Collet, J M van Dongen and 6 others
PMID 40143559WHAT IT FOUND
Professionals said hospital-to-home handovers relied on one-way letters and patients, often leaving primary care with incomplete information.
They wanted clear roles, a coordinator, and less overwhelming discharge paperwork for patients.
Key findings
01Information exchange from hospital to primary care often relied on one-way referral letters carried by patients, and primary care professionals reported incomplete information about recovery and next steps.
02Professionals said responsibility for organising discharge and follow-up was unclear, and hospital professionals believed nurses should coordinate ward communication.
03Professionals said the volume of discharge information often overwhelmed patients, and discharge communication was often poorly timed.
STILL TO COME
How it was doneWhat they foundWhat it means for PTsWhat it means for OTs
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What it does not show
All hospital participants worked in an academic hospital, so the findings may not apply to general hospital settings. Most information came from physical therapists, which may have unbalanced the themes toward physical therapy perspectives. The hospital participants came from four departments in an academic hospital, and primary care participants were recruited from the Amsterdam region. No patients or families were interviewed, so the findings describe professional perspectives, not patient-reported experiences. Member checking was limited: only two professionals provided feedback.
Declared interests
The authors declared no conflicts of interest. Funding: ZonMw.
The easy way to misread this
Do not read these professional perspectives as evidence that a coordinator, standardised letter, or multidisciplinary meeting improves readmissions or patient outcomes. The study asked professionals about their experiences and needs; it did not test an intervention or measure patient results.