title: The Lived Experience of the Hospital Discharge "Plan": A Longitudinal Qualitative Study of Complex Patients.
abstract: Transitions in care are a high-risk time for patients. Complex patients account for the largest proportion of healthcare costs but experience lower quality and discontinuity of care. The experiences of complex patients can be used to identify gaps in hospital discharge practices and design interventions to improve outcomes.
  
  
  
  We used a case study approach with serial interviews and chart abstraction to explore the hospital discharge and transition experience over 6 weeks. Participants were recruited from a small hospital in Toronto that provides care to complex patients living with human immunodeficiency virus (HIV). Framework analysis was used to compare data across time-points and sources.
  
  
  
  Data were collected from 9 cases. Participants presented with complex medical and psychosocial challenges, including substance use (n = 9), mental health diagnoses (n = 8) and a mean of 5 medical comorbidities in addition to HIV. Data were analyzed and reported in 4 key themes: 1) social support; 2) discharge process and transition experience; 3) post-discharge follow-up; and 4) patient priorities. After hospital discharge, the complexity of participants' lives resulted in a change in priorities and subsequent divergence from the discharge plan. Despite the comprehensive discharge plans, with referrals designed to support their health and activities of daily living, participants experienced challenges with social support and referral uptake, resulting in a loss of stability achieved while in hospital.
  
  
  
  Further investigation and changes in practice are necessary to ensure that discharge plans for complex patients are realistic within the context of their lives outside of the hospital. Journal of Hospital Medicine 2017;12:5-10.
authors.affiliation: Casey House, Toronto, Ontario, Canada.|Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Soo Chan
authors.initials: SC
authors.lastname: Carusone
authors.affiliation: Casey House, Toronto, Ontario, Canada.|Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Bill
authors.initials: B
authors.lastname: O'Leary
authors.affiliation: Casey House, Toronto, Ontario, Canada.
authors.forename: Simone
authors.initials: S
authors.lastname: McWatt
authors.affiliation: Casey House, Toronto, Ontario, Canada.|Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Ann
authors.initials: A
authors.lastname: Stewart
authors.affiliation: Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Shelley
authors.initials: S
authors.lastname: Craig
authors.affiliation: Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada.
authors.forename: David J
authors.initials: DJ
authors.lastname: Brennan
mesh_terms: D000328:Adult; D003266:Continuity of Patient Care; D005260:Female; D015658:HIV Infections; D006761:Hospitals; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D009864:Ontario; D010347:Patient Care Planning; D010351:Patient Discharge; D036301:Qualitative Research