Experiences of Older People Living with Frailty Transitioning from Hospital to Home — A Qualitative Descriptive Study
Bibliographic record
Abstract
This qualitative study explores the experiences of older people living with frailty, their informal caregivers, healthcare professionals, and administrators during the transition from hospital to home within the Ontario Health Teams (OHT) model. Using focus group discussions (FG1: older adults and caregivers, FG2: healthcare administrators, and FG3: healthcare professionals), the study identifies six key themes critical to successful care transitions: 1) healthcare as holistic care, 2) the therapeutic value of familiar surroundings, 3) the need for patient and caregiver voice and choice, 4) the challenges of navigating the disconnect between hospital and community care, 5) the importance of supporting informal caregivers, and 6) the impact of income, language, and equity on care access. The findings highlight significant communication, coordination, and resource allocation gaps impeding effective transitions. Such problems are associated with emotional strains of patients, caregivers, and health care providers, and higher chances of caregiver burnout and hospital readmission. The paper highlights the necessity of integrated, patient-centred care models, in which a smooth transition, effective communication, and active participation of patients and caregivers in the care planning are essential. A solution to these issues is the proposed Integrated Transitional Care Model (ITCM), based on the insights of the study, to enhance care coordination, decrease readmissions, and offer equitable care to older adults who may be frail. The study highlights the need to develop a collaborative healthcare system in which all stakeholders, including patients, caregivers, medical practitioners, and administrators, collaborate to facilitate smooth and well-coordinated transitions and better health results. The results present meaningful policy, practice, and research implications to improve care transitions of frail older adults in Ontario and elsewhere.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.008 | 0.012 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.002 |
| Science and technology studies | 0.009 | 0.008 |
| Scholarly communication | 0.004 | 0.004 |
| Open science | 0.002 | 0.005 |
| Research integrity | 0.002 | 0.003 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".