Transition from hospital to home care: a mixed methods study in light of Meleis's Theory.
Liasse Monique de Pinho Gama, Karoliny Ruama Carrenho Ribeiro, João Lucas Campos de Oliveira and 3 others
PMID 40105528WHAT IT FOUND
Patients and families rated hospital-to-home transition poorly: their care-transition score was 59.2 of 100, below 70 considered satisfactory.
Most had no post-discharge home visit, but daily-living dependence decreased from moderate to mild.
Key findings
01Low income stood out as a condition that inhibited care transition.
02Some patients said they were not fit for discharge and that pain was not managed.
03Patients’ average dependence in daily activities decreased from moderate to mild after discharge.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The sample was small and recruited for convenience: 26 patients and 18 family members from a public hospital. It excluded people in nursing homes, rural areas, outside the municipality, and patients who died or could not be visited after three attempts. It did not include professionals, so it captures only the patient and family side of transition. No discharge intervention was tested, so it cannot show that any change to discharge planning improved outcomes. The care-transition questionnaire has no official cut-off; the authors used a 70 point satisfactory level taken from other studies. Follow-up was only between ten and 30 days after discharge.
The easy way to misread this
Do not read the drop from moderate to mild dependence as proof that discharge planning caused recovery. This was a small observational study with no control group, and the care-transition score was 59.2 of 100, below the 70 point level the authors treated as satisfactory.