ArticleThe Gerontologist2019
Performance-Shaping Factors Affecting Older Adults' Hospital-to-Home Transition Success: A Systems Approach.
Article in The Gerontologist, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 28 papers, 4 of them syntheses that pooled it.
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Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
28 citing papers in PubMed, 4 syntheses or guidelines pooled it.
- Patient- and family-centred care transition interventions for adults: a systematic review and meta-analysis of RCTs.International journal for quality in health care : journal of the International Society for Quality in Health Care · 2023Pooled it
- Facilitators and inhibitors in hospital-to-home transitional care for elderly patients with chronic diseases: A meta-synthesis of qualitative studies.Frontiers in public health · 2023Pooled it
- Effectiveness of person- and family-centred care transition interventions on patient- oriented outcomes: A systematic review.Nursing open · 2021Pooled it
- Caregiver Experiences of Care Coordination for Recently Discharged Patients: A Qualitative Metasynthesis.Western journal of nursing research · 2020Pooled it
- Adaptation Model for Patient and Caregiver Dyads in Hospital-to-Home Transition: Theory Development and Content Validation.Healthcare (Basel, Switzerland) · 2026Article
- Exploring Patient and Caregiver Work and Continuity of Care During Hospital-to-Home Transitions of Care in the Canadian Context.Health expectations : an international journal of public participation in health care and health policy · 2026Article
- Leveraging Ergonomics and Human Factors (E/HF) for community impact: what have we learned about how to make a difference.Ergonomics · 2025Article
- Policy interventions for improving hospital-to-home transitions of care for older adults and informal caregivers: a qualitative study.Israel journal of health policy research · 2025Article
- A Qualitative Study of Factors That Influence Older Adults' Work on the Arduous Path to Spine Surgery.Health science reports · 2025Article
- Assessing patient work system factors for medication management during transition of care among older adults: an observational study.BMJ quality & safety · 2024Observational
- Application of a Human Factors and Systems Engineering Approach to Explore Care Transitions of Sepsis Survivors From Hospital to Home Health Care.Human factors · 2024Article
- Macroergonomic components of the patient work system shaping dyadic care management during adolescence: a case study of type 1 diabetes.Ergonomics · 2024Article
- Successful ability to stay at home - an interview study exploring multiple diagnosed older persons and their relatives' experiences.BMC geriatrics · 2024Article
- New horizons in systems engineering and thinking to improve health and social care for older people.Age and ageing · 2024Article
- Using Systems Engineering and Implementation Science to Design an Implementation Package for Preoperative Comprehensive Geriatric Assessment Among Older Adults Having Major Abdominal Surgery: Protocol for a 3-Phase Study.JMIR research protocols · 2024Article
- Article
- Self-care for people with heart failure: the importance of tele-nursing in the COVID-19 pandemic.Revista latino-americana de enfermagem · 2024Article
- Older Adults' Experiences Living With and Having Spine Surgery for Degenerative Spine Disease.The Gerontologist · 2023Article
- Care Partner Inclusion of People Hospitalized With Alzheimer Disease and Related Dementias: Protocol for a Mixed Methods Systems Engineering Approach to Designing a Health Care System Toolkit.JMIR research protocols · 2023Article
- "Why Do We Always Have to Focus on the Bad": A Strengths-Based Approach to Identify the Positive Aspects of Care From the Perspective of Older Adults Using a Secondary Qualitative Analysis.Journal of patient experience · 2023Article
Corrections and comments
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Authors and funding
4 authors.
Funding
Abstract
BACKGROUND AND
objectivesFacilitating older adults' successful hospital-to-home transitions remains a persistent challenge. To address this challenge, we applied a systems lens to identify and understand the performance-shaping factors (PSFs) related older adults' hospital-to-home transition success. RESEARCH DESIGN AND
methodsThis study was a secondary analysis of semi-structured interviews from older adults (N = 31) recently discharged from a hospital and their informal caregivers (N = 13). We used a Human Factors Engineering approach to guide qualitative thematic analysis to develop four themes concerning the system conditions shaping hospital-to-home transition success.
resultsThe four themes concerning PSFs were: (a) the hospital-to-home transition was a complex multiphase process-the process unfolded over several months and required substantial, persistent investment/effort; (b) there were unmet needs for specialized tools-information and resources provided at hospital discharge were not aligned with requirements for transition success; (c) alignment of self-care routines with transition needs-pre-hospitalization routines could be supportive/disruptive and could deteriorate/be re-established; and (d) changing levels of work demand and capacity during the transition-demand often exceeded capacity leading to work overload. DISCUSSION AND IMPLICATIONS: Our findings highlight that the transition is not an episodic event, but rather a longitudinal process extending beyond the days just after hospital discharge. Transition interventions to improve older adults' hospital-to-home transitions need to account for this complex multiphase process. Future interventions must be developed to support older adults and informal caregivers in navigating the establishment and re-establishment of routines and managing work demands and capacity during the transition process.
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