title: Health professional perspectives on systems failures in transitional care for patients with dementia and their carers: a qualitative descriptive study.
abstract: BACKGROUND
  Healthcare professionals engage in discharge planning of people with dementia during hospitalisation, however plans for transitioning the person into community services can be patchy and ineffective. The aim of this study was to report acute, community and residential care health professionals' (HP) perspectives on the discharge process and transitional care arrangements for people with dementia and their carers.
  
  
  METHODS
  A qualitative descriptive study design and purposive sampling was used to recruit HPs from four groups: Nurses and allied health practitioners involved in discharge planning in the acute setting, junior medical officers in acute care, general practitioners (GPs) and Residential Aged Care Facility (RACF) staff in a regional area in NSW, Australia. Focus group discussions were conducted using a semi-structured schedule. Content analysis was used to understand the discharge process and transitional care arrangements for people with dementia (PWD) and their carers.
  
  
  RESULTS
  There were 33 participants in four focus groups, who described discharge planning and transitional care as a complex process with multiple contributors and components. Two main themes with belonging sub-themes derived from the analysis were: Barriers to effective discharge planning for PWD and their carers - the acute care perspective: managing PWD in the acute care setting, demand for post discharge services exceeds availability of services, pressure to discharge patients and incomplete discharge documentation. Transitional care process failures and associated outcomes for PWD - the community HP perspective: failures in delivery of services to PWD; inadequate discharge notification and negative patient outcomes; discharge-related adverse events, readmission and carer stress; and issues with medication discharge orders and outcomes for PWD.
  
  
  CONCLUSIONS
  Although acute care HPs do engage in required discharge planning for people with dementia, participants identified critical issues: pressure on acute care health professionals to discharge PWD early, the requirement for JMOs to complete discharge summaries, the demand for post discharge services for PWD exceeding supply, the need to modify post discharge medication prescriptions for PWD, the need for improved coordination with RACF, and the need for routine provision of medication dose decision aids and home medicine reviews post discharge for PWD and their carers.
authors.affiliation: School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia. Ashley.Kable@newcastle.edu.au.
authors.forename: Ashley
authors.initials: A
authors.lastname: Kable
authors.affiliation: Faculty of Health, University of Technology, 15 Broadway, Ultimo, NSW, 2007, Australia. Lynnette.Chenoweth@uts.edu.au.|Centre for Healthy Brain Ageing, University of New South Wales, G27, Botany Rd, Randwick, NSW, 2031, Australia. Lynnette.Chenoweth@uts.edu.au.
authors.forename: Lynnette
authors.initials: L
authors.lastname: Chenoweth
authors.affiliation: School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia. Dimity.Pond@newcastle.edu.au.
authors.forename: Dimity
authors.initials: D
authors.lastname: Pond
authors.affiliation: Hunter New England Local Health District, Rankin Park, NSW, 2287, Australia. Carolyn.Hullick@hnehealth.nsw.gov.au.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Hullick
mesh_terms: D000368:Aged; D001291:Attitude of Health Personnel; D001315:Australia / Q000453:epidemiology; D017028:Caregivers; D003657:Decision Making; D003661:Decision Support Techniques; D003704:Dementia / Q000453:epidemiology / Q000628:therapy*; D005069:Evaluation Studies as Topic; D017144:Focus Groups; D005500:Follow-Up Studies; D006282:Health Personnel; D006801:Humans; D008875:Middle Aged; D009735:Nursing Homes; D010347:Patient Care Planning / Q000458:organization & administration* / Q000592:standards; D010351:Patient Discharge / Q000592:standards*; D000069341:Transitional Care / Q000458:organization & administration* / Q000592:standards