Purpose of the study: The study's purpose was to determine nurses' opinions of sending patients from the hospital to home with home health services.
Primary practice setting: The study occurred in the Charleston, South Carolina, Tricounty area (Berkeley, Charleston, and Dorchester counties). Home health agencies and hospitals were invited to participate.
Methodology and sample: The study used a survey design to gather information on nursing perceptions of current practices and needed changes to improve transition of patients. The population was nurses (licensed practical nurses (LPNs) and registered nurses (RNs)) employed at inpatient hospitals or home health agencies in the area. Thirty-four RNs responded with no LPNs respondents. Agency administrators/chief nursing officers agreed for their agencies to participate and distributed the survey using a Research Electronic Data Capture (REDCap) Internet-based survey tool. Using the survey results and information from a literature review, the study developed a list of propositions, which participating administrators reviewed, for improving transitions to home.
Results: Both home health and hospital nurses reported a need to improve the process of sending patients from hospital to home with home health services.
Implications for case management practice: This study provides hospitals and home health agencies with propositions to facilitate the establishment of a process to communicate effectively patients care needs and streamline the discharging patients from the hospital to home health care; thus, improving patient transition. Case managers and discharge planners will need interagency collaboration along with evidence-based interventions to transition patients from the hospital to home with home health services with various populations. Direct patient care nurses in both hospital and home health settings should share the same accountability as case managers to ensure successful transitions.