Reducing delayed transfer of care in older people: A qualitative study of barriers and facilitators to shorter hospital stays

Abstract Introduction Growing numbers of older patients occupy hospital beds despite being ‘medically fit’ for discharge. These Delayed Transfers of Care amplify inefficiencies in care and can cause harm. Delayed transfer because of family or patient choice is common; yet, research on patient and family perspectives is scarce. To identify barriers to, and facilitators of, shorter hospital stays, we sought to understand older people's and caregivers' thoughts and feelings about the benefits and harms of being in hospital and the decisions made at discharge. Methods A multimethod qualitative study was carried out. Content analysis was carried out of older people's experiences of health or care services submitted to the Care Opinion online website, followed by telephone and video interviews with older people and family members of older people experiencing a hospital stay in the previous 12 months. Results Online accounts provide insight into how care was organized for older people in the hospital, including deficiencies in care organization, the discharge process and communication, as well as how care was experienced by older people and family members. Interview‐generated themes included shared meanings of hospitalization and discharge experiences and the context of discharge decisions including failure in communication systems, unwarranted variation and lack of confidence in care and lack of preparation for ongoing care. Conclusion Poor quality and availability of information, and poor communication, inhibit effective transfer of care. Communication is fundamental to patient‐centred care and even more important in discharge models characterized by limited assessments and quicker discharge. Interventions at the service level and targeted patient information about what to expect in discharge assessments and after discharge could help to address poor communication and support for improving discharge of older people from hospital. Patient or Public Contribution The Frailty Oversight Group, a small group of older people providing oversight of the Community Aging Research 75+ study, provided feedback on the research topic and level of interest, the draft data collection tools and the feasibility of collecting data with older people during the COVID‐19 pandemic. The group also reviewed preliminary findings and provided feedback on our interpretation.

Trusts incurring costs for patients who are ready to leave hospital-DToCs cost providers an estimated £173 million in 2016/17. 5 DToC may have detrimental physical and emotional effects for hospitalized older people. Functional decline and increased frailty occur in a third of older patients. 6 Patients with functional decline or frailty can become 'trapped' in hospital beds, and their more complex needs at the time of discharge place greater reliance on finite social or community support. 1,7,8 Hospitals can of course improve older patients' health and provide rehabilitation to increase independence and overall quality of life. While hospitalization benefits may tail off with extended stays, 9 conceptualizing 'benefit' as more than 'clinical effectiveness' and incorporating patients feeling cared for, safe, helped to manage at home and relief for families suggests that positive effects are possible. 10 These positive aspects are not trivial; feeling safe can increase hope and control and feeling better can be a function of improved physical condition generally as well as specific symptom resolution. 11,12 Feelings of greater control also impact on choices. 13 Research from a patient and family perspective tends to focus on the impact of hospital stays on older people and caregivers; there is an evidence gap specifically on the decisions made around the time of discharge and their relationship with the perceived benefits and harms of extended stays.
Policies catalysed by the COVID-19 pandemic, such as 'discharge to assess,' 14 whereby assessments of care needs take place at home or in the community, have been variably implemented and their effects on outcomes are uncertain. Simply shifting the locus of decision-making from a clinical setting to a domiciliary one, however, ignores differences between and within system elements and supraorganizational units such as integrated care systems. Consequently, historic inequalities in processes, care and outcomes for older people could be perpetuated and even exacerbated. 15 Sixteen percent of DToC in England can be attributed to carer or familial choice, behaviours 4 or lack of awareness. Examples include preferences for specific care homes, refusing alternatives offered, difficulty attending planning meetings, 16 being unaware of the cost implications of care, unavailability due to prearranged holidays, refusing to accept equipment and familial conflict around discharge plans. 17 Age UK (the UK's largest charity for older people) suggests that family-attributed causes of DToC are more likely to represent reasonable objections, inadequate communication or lack of decisional involvement. 18 We sought to understand older people's and caregivers' thoughts and feelings about the benefits and harms of being in hospital and the decisions made at the time of discharge. We aimed to identify common barriers and facilitators to shorter hospital stays and use the findings to inform implementation of the new 'discharge to assess' policy.

| Conceptual framework
The theoretical framework for the study was 'transitions theory'. 19 In transitions theory, the relationship between transition conditions and outcomes has been supported and we thought that the model could translate to DToC as a transition. The authors therefore conceptualized DToC as a transitional state with opportunities for both positive outcomes as well as harm. Based on the tenets of the theory, we proposed that the key transition conditions (health service, social care and family or patient) could facilitate or constrain the transition out of hospital and influence outcomes including cost, prolonged hospital stay and physical and emotional impact on older people, as SMITH ET AL. | 2629 well as patient and family thoughts and feelings. These thoughts and feelings could in turn influence distal outcomes, such as seeking earlier discharge and better-informed patient and family discharge decision-making, leading ultimately to shorter hospital stays for older people. This study explores the transitional state of DToC and its impact on patient and family thoughts and feelings.

| MATERIALS AND METHODS
This was a sequential QUAL-QUAL study 20 with two components: A desk-based review of older people's experiences of health or care services submitted to the Care Opinion online website, 21 followed by telephone or video interviews with older people, and family members of older people, who had experienced a hospital stay within 12 months. Both components contributed equally to the study findings.
Participants in both components were older people aged 75 years and older. Although globally the definition of older people has tended to be those aged 65 years or older, there is no clear rationale for this and there have been recent calls to redefine chronological old age.
The Community Aging Research 75+ (CARE75+) study, from which interview participants were recruited for this study, recruits older people aged 75 years and older because at this age, important laterlife conditions are more prevalent and so it is more useful for studying epidemiological aspects in a time-limited cohort. 22 The authors therefore adopted this definition for eligible participants across all elements of the study to ensure consistency.

| Desk-based review of online care stories
Care Opinion is an online platform for sharing people's experiences of UK health and care services. We searched for submissions by older people (aged 75 years and older) or family members of older people detailing their experiences of recent hospital stays and/or discharge.
Searches were conducted in November 2020 and were limited to those published since November 2018 to ensure relevance to contemporary care processes and pathways.
One author (H. S.) searched Care Opinion using keywords based on the inclusion criteria (Table 1). Two authors (C. G. and I. H.) removed duplicates and screened retrieved stories for inclusion ( Table 2) and exported them into an Excel spreadsheet. C. G. and I. H. divided the stories equally between them and content-analysed them using the conceptual framework for the study. Analysis began deductively-using conceptual framework constructs as initial codes-but concepts were also derived inductively as reading and analysis progressed. 23 One author (H. S.) periodically reviewed the codes and subcodes with C. G. and I. H., to resolve any issues and ensure coding consistency. After coding was finished, three authors (H. S., C. G., I. H.) reviewed the spreadsheet and regrouped coded data into categories of related concepts identified across the entire data set. Categories were further refined into six main themes (see the Supporting Information: File S1). These findings highlighted older people's and family members' positive and negative experiences of care and discharge, pertinent to the study research questions, and helped inform the topic guides used in telephone interviews with older people and family members.
T A B L E 1 Inclusion criteria for online care stories

Participants
Men and women aged 75 years and older.

Intervention
Hospitalized for any period of time for any condition or illness.  10 Using the inclusion criteria (Table 3), the initial sample included at least 10 purposefully sampled older people and family members with experience caring for an older relative during admission and after discharge. It was estimated that 3-5 more interviews would be required until no new ideas emerged-the stopping criterion. 24 The sample was monitored for balance of inclusion criteria as recruited progressed. After each interview, the audio file and written notes were reviewed by H. S.
to identify key issues and evaluate data saturation-which was achieved after 10 interviews with family members, and 6 with older people.

| Recruitment
Older people and family members were recruited from a variety of sources:

| Analysis
Audio recordings were transcribed verbatim, checked for accuracy and analysed using the 'codebook' approach to thematic analysis. 29 One author read a selection of transcripts, listened to a selection of audio files and read notes taken after each interview, and based on this, identified key concepts and ideas in the data set and listed these as initial codes. Selected transcripts and the code list were shared Family members with experience of caring for a relative during admission and after discharge from hospital. English speaking. Able to give consent.

Intervention
Older people hospitalized for any period for any condition or illness in the last 12 months.

Context
A hospital stay is defined as being admitted and discharged from hospital for any length of time and for any reason. shows how the team moved from codes to themes and subthemes.

| Content analysis of online care stories
A total of 371 Care Opinion stories were content-analysed; the majority (84%) were stories authored by family members or caregivers of older people and 13% were older people's stories (Table 4). Just over half the stories featured older women (53%) and 38% were about older men (in 9.2% of the stories, the gender was unknown and in 0.5%, more than one person was mentioned). In stories that mentioned age, 33% featured older people aged 85 years and older, 13% were aged 74-84 years and 4% featured those younger than 75 years (age was unknown in 49.6% of stories). The ethnicity of those submitting stories to the Care Opinion website was not recorded. Eighty-six percent of the stories were submitted during the COVID-19 pandemic.

| Interviews with older people and family members
Ten family members and six older people were interviewed ( Table 6).
Most of those interviewed were over the age of 80 years and all were of White British origin. More men (62%) than women (38%) were interviewed. Family members tended to be sons or daughters (90%) of older people who had been in hospital. Older people had experienced hospital stays of varying lengths, with the majority admitted for four or more weeks (38%), and most experiencing the hospital stay during the COVID-19 pandemic (69%).
Six themes were generated (see the Supporting Information: File S2 for illustrative quotes).

| Older people and families appreciate the rationale for shorter hospital stays
This theme captures a range of beliefs and feelings about being in hospital expressed by older people and family members, including preferring to be at home, not wanting to be a burden on the health service and aspects of the hospital environment that were not conducive to recovery. These amounted to an appreciation of the need for shorter hospital stays (see the Supporting Information: File S2 for illustrative quotes).

(41)
• Bed moves and transfers of older relatives between hospitals, between wards, corridors to ward or aisle to ward and multiple bed moves while in hospital.
• Family members concerned about the number of times their relative had been 'shifted around', sometimes late at night.
• Transfers described as harmful or not ideal for elderly, frail people.

(22)
• Time taken to assess older people on admission, and older relatives being left 'for hours on a trolley' or in corridors before procedures.
• Staffing levels described as inadequate and wards as 'seriously understaffed'; relatives noticed that staff were 'overstretched' and trying their best under difficult circumstances.
• Staff doing their best 'despite the organization, not because of it', in a system that seems 'broken' and a 'service under constant pressure'.
Time taken at points in the care pathway 0 (0)

(7)
Staffing levels 2 (33) 17 (24) Management shortcomings 1 (17) 14 (20) • Having a dedicated nurse per patient meant that it was impossible to get help if that nurse was not available.
• Reliance on agency or bank staff who had no organizational knowledge and knew little about individual patients.
• Lack of continuity of care manifest as 'different doctors and nurses almost every day'.

Disorganized discharge processes
Discharge processes 24 (49) 124 (39) • The discharge process was sometimes described as 'faultless' and 'impressive', with follow-up appointments made, referral to community services in place and 'detailed instructions' for themselves and the GP.
• Negative experiences included being discharged with 'no explanation' or 'no discharge letter', no discussion of 'how to cope when finally at home' and a process that was 'not straightforward'.
• Family described disorganized discharge processes; 'chaotic', with older people discharged without staff 'realizing they needed to inform next of kin', discharged at a different time than expected and family having received no notice of discharge or finding out 'by accident'.
• Few older people who requested transport home as it was late at night, or they had alternative but were told by staff that it 'was not their responsibility' to arrange transport.
• Older people referred to being discharged from hospital swiftly, in a matter of days, after surgery or operations. Two

(28)
• Prolonged waits for 'hours' and sometimes until late at night for various procedures to happen before discharge including scans, physiotherapist assessment, consultant opinion or nurse assessment.
• Family recounted transport delays, relatives waiting hours for an ambulance to take them home, sometimes due to lack of communication with ambulance crews or poor communication between staff and family.
Communication is adequate but often deficient Information and communication 29 (59) 209 (65) • Being 'left in the dark' and being ignored by staff when asking for information about their relative's condition; minority received 'inconsistent' or 'conflicting' information each time they called.
• Difficulty contacting the hospital or the ward by phone; having to call the hospital 'repeatedly'; phones 'frequently left unanswered'.
• 'Grateful' to doctors and nurses for taking time to answer questions or explain aspects of treatment and being kept updated even though staff 'were very busy'.
• Older people said that staff were 'informative' and 'friendly', 'helpful', 'happy to answer questions' and explained procedures 'quite clearly' and in a 'language I could understand'. Minority highlighted inadequate information and staff who lacked 'common decency to speak to me'.
Communication between staff 4 (14) 21 (10) Communication with older person 18 (62) 33 (16) Lack of communication with carer/ family 7 (24) 155 (74) What it means to be an older person in hospital • Relatives mentioned friendly, cheerful and positive staff and that 'nothing was too much trouble' despite the busy environment they worked in (all cadres of staff).
Friendly and positive demeanour of staff 12 (31) 53 (30) Staff patience and kindness 14 (36) 51 (29) Being treated with dignity and respect 7 (18) 25 (14) Negative staff care 9 (18) 76 (24) • Older people mentioned staff making assumptions that they were 'not capable of making decisions', arrogance or a lack of compassion among some staff towards older people who may be frightened or suffering with multiple conditions. for long periods; ignored by staff, requests for blankets, medication, food and water were ignored and 'basic human needs' were not met.  • The few stories that mentioned the impact of COVID-19 centred on family not being allowed to accompany older people on admission or to visit; most understood that this was not possible.

Family members take on liaison and advocacy roles
Family and caregiver support 4 (8) 135 (42) • Family sometimes took on unanticipated liaison and advocacy roles for older relatives, including being relied upon for information, asked to 'liaise between doctors' on treatment decisions and negotiate with community services including the district nurse, mental health and safeguarding teams.
• Family members cared for and supported relatives on the ward. This ranged from washing, feeding and help getting to the bathroom, to assisting their relative in and out of bed and into chairs or wheelchairs; many mentioned that staff were too busy, overworked or were not allowed to help.
• Several family members said they felt that they had to be present on the ward to ensure that their relative was

Family appreciates the rationale for shorter stays
Family members explained how their older relative wanted to be at home rather than in hospital for longer than necessary. They talked about how their older relative liked being at home, explained that home was the right place for a quicker recovery and that an unfamiliar environment was not helpful. Family members also mentioned that getting patients home as soon as possible was understandable from a service perspective.

Not wanting to be a burden
Older people mentioned that that they were not keen on being in hospital longer than they needed to be and held strong views about being a 'burden' (sic) on the health service. They also talked about having to accept being in hospital and that it was the right place to get the care that was needed. Many older people also mentioned that they wanted to be at home, where they felt they would improve or get better quicker.

Hospital as relief
Several family members described feeling relieved when their older relative was admitted to hospital. Older people also talked about being 'in the best place' for the care they needed, being looked after and feeling like they were being taken care of.

Boredom and lack of social interaction
Some family members mentioned that their older relatives had described the helplessness of feeling 'locked in' the hospital environment, while others described the emotional impact of feeling lonely, especially not being able to see their spouse due to COVID-19 restrictions. Boredom was frequently mentioned, and the lack of mental stimulation and opportunity for social interaction was a concern.
Noise and ward environment not conducive to recovery The impact of the hospital environment featured frequently in accounts. A distinction was made between 'mechanical noise' from machines or transport of people and equipment up and down the ward and 'people noise' from loud conversations and people constantly coming and going. Related to this was the inability to sleep, due to being woken up by the noise and activity on the ward.

Amount and quality of information provided by staff varied
Many family members talked about the difficulties that they experienced trying to communicate with the hospital; some had to call several times to get through to the ward. When they did make contact, the level of communication seemed to vary by staff member.

Feeling listened to facilitates care
Several family members said that they felt listened to and staff worked with them to facilitate care of their relative. A few family members of older people with dementia and/or visual impairments highlighted that they wanted to support their relative but felt they were not always listened to or trusted by staff to provide that support.

Communication between health and social care lacking
Family members became aware of the relationship between the hospital staff and social care teams and reported that there seemed to be no link between the services and no evidence of them working together. There was a suggestion that a communications coordinator could facilitate communication between all parties and make discharge more efficient.

| Unwarranted variation and lack of confidence in care
This theme highlights the inconsistency in the care of older people while in hospital and how this affected confidence in the care provided. The theme also emphasizes the important difference that individual staff members can make at the time of discharge.

Care varied depending on staff attitude and personality
Care provided to older people while in hospital seemed to vary.
This was experienced as inconsistency, and the general feeling was that care depended on staff capability and commitment. Some family members did encounter staff who they felt genuinely cared, but it seemed that this was the exception. The variation in care seemed to cause anxiety among family about the level of care received and how their relative was being treated.

Family members lacked confidence in care
Some family members appeared to lack confidence that staff were doing their best. This was linked to their experience of relatives not having their basic needs met and lack of age-appropriate care for older people. Others felt that when staff were empathetic or took an interest, it was much easier to have confidence that their relative was receiving appropriate care.

Individual staff members played critical roles
Some family members mentioned a particular staff member who seemed to play a critical role in the discharge process. These were often nurses or social workers who knew the system, coordinated every step in the process and helped families to navigate social care.
Often, family members described feeling fortunate to have had such help because it was not regarded as usual practice.

| Hospital discharge process caused frustration and anxiety
This theme captures how hospital discharge was experienced by older people and family members. It describes the frustration and anxiety that the process caused, as well as aspects that seemed to reassure patients and family and facilitate the transfer home.

Discharge experienced as medical needs assessment
For many family members, discharge of their older relative was experienced in terms of having medical needs assessed and 'clinical sign off'. For some, the focus on being medically fit caused anxiety and family members worried about their relative being discharged too soon.

Older people frustrated by discharge delays
Several older people talked about discharge delays, resulting in waits of several hours or more. Waiting for medication to be prescribed and for transport to be arranged seemed to be the two main reasons for delays.
Several described long waits for patient transport and ad hoc arrangements instead of a more organized system of allocating people to vehicles. Whatever the delay, older people were frustrated at waiting around for what felt like long periods of time, especially if they had got dressed, packed their bag and were ready to go.

Quicker discharge due to COVID-19
For a few family members, not being able to see their older relative due to COVID-19 restrictions heightened their anxiety about discharge because they had been unable to see them and assess for themselves if they were fit to go home. Some thought that the staff wanted discharge to be quicker and got the impression staff were quite anxious to discharge people.

Family excluded from the discharge process
There was a feeling among family members that they had not been involved in the discharge process. Some family members seemed relieved to not be involved, to not have the responsibility or because they had little to add to the decisions being made. Others were concerned about a lack of planning for ongoing care, including more information about the long-term outlook, and support at home.

Aspects of care that facilitated discharge
Aspects of care that seemed to facilitate the discharge process included being discharged to a 'virtual ward' or bed-based intermediate care (e.g., in a care home, community hospital or rehabilitation unit), which was described as reassuring by family and older people.
Older people also mentioned the efficiency, availability and excellent care received from virtual ward staff. Family members mentioned other aspects that helped them and their relative prepare for discharge, including having information about how the discharge process worked.

| Family and older people unprepared for ongoing care needs
This theme highlights how unprepared family members were for the ongoing care needs of their older relative. This was manifest as not being told about the level of support that would be required, as well as feeling frustrated at not understanding how the health and social care systems worked. There was a perception that communication at transitions between secondary and primary/community care (e.g., district nurses and other therapy services) was where the system broke down.
No help to navigate the social care system Family members expressed frustration at not being able to navigate the social care system in anticipation of their relative being discharged from hospital, especially patients not in receipt of government funding, who felt abandoned. For those being discharged to care homes, the lack of understanding about funding and how the system worked was even more acute. Others felt like they had not grasped or were not told about the level of support their relative might need once at home.

Disjointed primary and community care
Family members described how the care offered to their relative in the community was inadequate, to the extent that the system felt fractured. Some mentioned the lack of contact from GPs and having to follow up or arrange appointments themselves.
Others experienced disjointed planning and management from hospital to primary care and being passed from department to department. Older people experienced inconsistency in district nurse availability and felt that staffing or funding levels were to blame.
3.2.6 | Factors affecting implementation of 'discharge to assess' This theme captures what older people and family members thought about the discharge to assess model. Many felt that it was a good idea, supported by their view that medical assessment should drive discharge decisions when an older person is able to manage basic functional activities, with additional assessment in their usual environment. Individualized predischarge assessment was thought to be important; one family member cautioned against viewing patients as Amazon parcels.
Belief that discharge should be medically driven A dominant view among family members was that medical and functional assessment should drive discharge decisions. Some acknowledged that discharge assessment should consider more than physical fitness, such as assessment of psychological and emotional well-being, to prevent people being sent home without support.
Some considered discharge to assess a good idea but were not clear where people who still needed care but were unable to afford nursing care or had no family to take care of them would be discharged to.
Older people seemed to think that the discharge to assess policy was a good idea and would prevent institutionalization.
Barriers to implementing 'discharge to assess' Older people and family members recognized potential patient safety risks with 'discharge to assess'. An overriding concern was that without the right support in place before discharge, people would return to hospital with potentially more serious medical conditions.
Another strong view related to the capacity of community services (e.g., district nurses) to manage older people discharged to be assessed. For some, the lack of state-funded nursing homes combined with the demand from those without financial means was developing into a national crisis that required a solution.
Facilitating 'discharge to assess' The hospital environment added to older people's stress and influenced preferences for recovery at home and early discharge.
Hospital stressors have been characterized as an acquired generalized risk called 'posthospital syndrome,' which adversely affects recovery and can leave older people vulnerable to adverse events after discharge. 33

| Research implications
The barriers and facilitators to shorter hospital stays identified in this study provide a framework for further research on implementation of discharge to assess in older people. For example, the framework could be used to assess existing discharge processes or to specify principles in the design of new discharge to assess models for older people. The suggested recommendations represent service adaptations that could be piloted to improve discharge to assess in older people.
More research is needed into the cultures and behaviours in NHS organizations that deter staff from providing high-quality, safe, respectful, patient-centred care. Research is needed to understand how behaviours become routine and normalized 56,57 and to identify the organizational cultures and behaviours that threaten care quality and safety. 58 At a local level, trusts need to make the most of the range of methods available to collect feedback from patients and family on problems with delivery of care. 59 There can sometimes be a gap between generating data on patient experience and making decisions to improve; this requires skills to analyse large amounts of diverse data and time to discuss and reflect on how to translate findings into action. 60

| Study limitations
This study has several limitations. First, the coronavirus pandemic and