title: "Just another fish in the pond": the transitional care experience of a hip fracture patient.
abstract: BACKGROUND
  Miscommunication and lack of coordination can compromise care quality and patient safety during transitions in care, especially for medically complex older adults. Little research has been done to investigate care transitions from the perspective of those receiving and providing care.
  
  
  METHODS
  This study explored multiple care transitions for an elderly hip fracture patient, post-surgery. Interviews and observations were conducted with the patient, their family caregivers, and health care providers, at each point of transition between four different care settings.
  
  
  RESULTS
  FOUR KEY THEMES WERE IDENTIFIED OVER THE PATIENTS CARE TRAJECTORY: 'Missing Crucial Coversations'-Patient and family caregivers did not feel involved or informed about decisions in care; 'Who's Who'-Confusion about the role of health care providers; 'Ready or Not'-Not knowing what to expect or what is expected; and, 'Playing by the Rules'-Health system policies and procedures hinder individualized care.
  
  
  CONCLUSIONS
  Study findings point to the need for the health care system to engage patients and family caregivers more fully and consistently in the process of care transitions as well as the importance of understanding these processes from multiple perspectives. Recommendations for system integration are proposed with a focus on transitional care.
authors.affiliation: School of Public Health and Health Systems, University of Waterloo, Ontario, Canada.
authors.forename: Justine
authors.initials: J
authors.lastname: Toscan
authors.forename: Brooke
authors.initials: B
authors.lastname: Manderson
authors.forename: Selena M
authors.initials: SM
authors.lastname: Santi
authors.forename: Paul
authors.initials: P
authors.lastname: Stolee
keywords: caregivers; ethnography; hip fracture; patient experience; qualitative research; transitional care