Clinician Roles and Responsibilities During Care Transitions of Older Adults

Authors

  • Nancy L. Schoenborn MD,

    Corresponding author
    • Division of Geriatric Medicine and Gerontology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
    Search for more papers by this author
  • Alicia I. Arbaje MD, MPH,

    1. Division of Geriatric Medicine and Gerontology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
    Search for more papers by this author
  • Kathryn J. Eubank MD,

    1. Division of Geriatrics, Department of Medicine, San Francisco Veterans Affairs Medical Center, University of California at San Francisco, San Francisco, California
    Search for more papers by this author
  • Kenric Maynor MD, MPH,

    1. Department of Hospitalist Medicine, Geisinger Wyoming Valley Medical Center, Geisinger Health System, Wilkes-Barre, Pennsylvania
    Search for more papers by this author
  • Joseph A. Carrese MD, MPH

    1. Division of General Internal Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
    Search for more papers by this author

Address correspondence to Nancy L. Schoenborn, Division of Geriatric Medicine and Gerontology, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Building, Center Tower, Suite 2200, Baltimore, MD 21224. E-mail: nancyli@jhmi.edu

Abstract

Objectives

To identify the perceived roles and responsibilities of clinicians during care transitions of older adults.

Design

Qualitative study involving 1-hour in-depth semistructured interviews. Audiotapes of interviews were transcribed, coded, and analyzed, and themes and subthemes were generated.

Setting

An acute care hospital, a skilled nursing facility, two community-based outpatient practices, and one home healthcare agency.

Participants

Forty healthcare professionals directly involved in care transitions of older adults (18 physicians, 11 home healthcare administrative and field staff, four social workers, three nurse practitioners, three physician assistants, and one hospital case manager).

Measurements

Perspectives of healthcare professionals regarding clinicians' roles and responsibilities during care transitions were examined and described.

Results

Content analysis revealed several themes: components of clinicians' roles during care transitions; congruence between self- and others' perceived ideal roles but incongruence between ideal and routine roles; ambiguity in accountability in the postdischarge period; factors prompting clinicians to act closer to ideal roles; and barriers to performing ideal roles. A conceptual framework was created to summarize clinicians' roles during care transitions.

Conclusion

This study reports differences between what healthcare professionals perceive as ideal roles of clinicians during care transitions and what clinicians actually do routinely. Certain patient and clinician factors prompt clinicians to act closer to the ideal roles. Multiple barriers interfere with consistent practice of ideal roles. Future investigations could evaluate interventions targeting various components of the conceptual framework and relevant outcomes.

Ancillary