Exploring Stakeholder Perspectives on the Transitional Care Needs of Elderly Patients from Hospital to Home: A Phenomenological Study in Shanxi Province, China

Introduction

“Aging and health” represent a significant global public health challenge. From 2000 to 2020, the proportion of people aged 60 and above in developed countries increased from 19.5% to 25.7%, while in developing countries, it rose from 6.8% to 9.2%.¹ China, one of the fastest-aging nations globally, is projected to see its elderly population grow from 18.7% in 2020 to between 32.9% and 37.6% by 2050.^2,3 In Shanxi Province, northern China, 18.92% of the population is 60 and older, making aging-related challenges particularly severe.² However, Shanxi faces relatively poor healthcare infrastructure, with per capita health expenditure ranking low nationwide.^4,5 This situation, combined with the increasing aging trend, intensifies the difficulties in addressing aging issues in this region.

Data indicates that over 75.8% of elderly individuals in China have at least one chronic disease, and the risk of multiple chronic conditions rises significantly with age, making aging with illness increasingly common.^6,7 Unlike the general population, the elderly frequently move between different care settings, especially during the hospital-to-home transition. Their complex health conditions and care needs make them prone to fragmented care during these transitions.⁸ During hospitalization, elderly patients are largely dependent on healthcare professionals, but after discharge, due to limited self-care knowledge and skills, both elderly individuals and their caregivers face a significant burden of care. This burden is compounded by insufficient post-discharge healthcare support, further complicating the management of health problems at home and increasing the risk of adverse health outcomes. Studies show that unplanned readmission rates among the elderly are significantly higher than in the general population, with nearly 25% of elderly patients experiencing adverse outcomes during the transitional period.^9,10 Transitional care services have been proposed as a solution to reduce unplanned readmissions.^11,12 However, delivering effective transitional care requires not only meeting the diverse needs of the elderly but also optimizing the use of available social resources. Therefore, this study aims to explore the care needs of elderly patients during the hospital-to-home transition in Shanxi Province, providing a scientific basis for improving transitional care services and ultimately enhancing health outcomes for elderly patients.

Research on the hospital-to-home transition for elderly patients internationally has developed standardized transitional care models and intervention plans aimed at improving transitional experiences and health outcomes.^11,12 Through interviews with elderly patients and their caregivers in Turkey, Dolu et al emphasized the significance of patient-centered transitional care, highlighting the need to meet both medical and emotional needs while enhancing collaboration among healthcare providers and caregivers.¹³ Similarly, Petersen et al, based on interviews with Danish hospital nurses, identified challenges such as communication barriers, fragmented care, and insufficient involvement of patients and families in decision-making during the transition.¹⁴ They suggested building a more comprehensive support system to ensure accessible medical resources and effective communication.¹⁴ These studies demonstrate that international research on the needs of transitional care has advanced, emphasizing the importance of understanding these needs from the perspectives of healthcare providers, patients, and caregivers to deliver personalized and integrated care services. In contrast, related research in China primarily focuses on the development of transitional care models. Zhang et al designed a mobile health-based transitional care service involving hospitals, communities, and families, aimed at improving health indicators such as blood pressure, lipid levels, and self-management abilities in elderly diabetic patients.¹⁵ However, these studies often center on symptom management, overlooking the multidimensional needs of elderly patients, including psychological, social, cognitive, and environmental factors. Additionally, regional disparities significantly affect the needs of elderly patients. For example, Shanxi Province faces prominent issues such as inadequate medical support and an underdeveloped social support system. However, current research does not sufficiently reflect the actual needs of elderly patients in these areas. Therefore, it is of great practical significance to conduct in-depth exploration of the transitional care needs of elderly patients in such regions to address these gaps effectively.

Stakeholders refer to individuals or groups that can influence or be influenced by the achievement of an organization’s goals.¹⁶ Stakeholder theory posits that the realization of organizational goals requires the support and joint efforts of relevant stakeholders, whose actions can positively or negatively affect the organization, with their influence varying over time and in different contexts.¹⁷ In the case of hospital-to-home transitional care, this process involves a multidisciplinary team of doctors, nurses, and other professionals, with patients and caregivers participating to complete the process. Nurses are a critical component of transitional care, acting as both designers and providers of care services. Their involvement spans the entire continuum, from hospital admission, through discharge and transfer, to home rehabilitation. Nurses’ knowledge of patient conditions and coordination with other professionals are essential for a successful transition.¹⁸ Therefore, nurses’ attitudes and perspectives on transitional care directly impact its quality. Despite this, literature on the views of healthcare professionals, who play a key role in coordinating transitional care, remains limited. Caregivers, similarly, play a vital role in improving elderly patients’ quality of life by providing essential daily support and emotional care.¹⁹ Given that transitional care involves multiple stakeholders, it is insufficient to rely solely on patients’ perspectives. A comprehensive understanding of the needs of elderly patients during the hospital-to-home transition requires identifying and addressing the concerns of all stakeholders. Moreover, the needs for transitional care can vary among different stakeholders across countries and regions. Therefore, this study, grounded in stakeholder theory, uses semi-structured interviews with elderly patients, caregivers, and nurses to explore their perspectives on transitional care, with the aim of developing a more scientific and comprehensive care model.

Methods

Study Design

This study employed a descriptive phenomenological qualitative research approach, utilizing in-depth, face-to-face, semi-structured interviews to comprehensively explore the needs of elderly patients, caregivers, and healthcare professionals during the hospital-to-home transitional care period. Adhering to the Consolidated Criteria for Conducting and Reporting Qualitative Research (COREQ) guidelines.²⁰

Participants

Participants were recruited using purposeful sampling from the comprehensive medical departments at Shanxi Bethune Hospital between June and December 2023. We employed maximum variation sampling to capture a diverse range of perspectives, considering factors such as age, gender, educational background, chronic disease types, and ability to perform daily living activities. Caregivers and nurses were selected based on inclusion and exclusion criteria, regardless of whether they had previously provided care for the interviewed patients, to ensure broad representation.

The inclusion criteria for elderly patients were: (1) age ≥ 60 years; (2) discharged after hospitalization in a tertiary hospital, without limitation on the number of previous admissions; (3) capable of participating in the survey, without communication barriers and capable of accurately answering questions; (4) having at least one chronic disease; (5) informed consent obtained and willingness to participate in the study. The exclusion criteria for elderly patients were: (1) severe cardiovascular or cerebrovascular diseases, liver or kidney failure; (2) terminal stage of illness; (3) cognitive impairments.

The inclusion criteria for caregivers were: (1) being the primary caregiver of the patient for at least 3 months; (2) family members such as spouses, children, and relatives of the patients; (3) willingness and ability to fully express their true thoughts. The exclusion criterion was: having any understanding or communication barriers.

The inclusion criteria for nursing staff were: (1) holding a middle-level or higher professional title; (2) having at least 5 years of experience in geriatric nursing; (3) with a history of providing transitional care services to elderly patients; (4) willingness to participate in the study. The exclusion criteria were: nursing staff currently undergoing standardized training, advanced studies, or rotations.

Procedure

Interviews with the three groups were conducted sequentially—first with elderly patients, followed by caregivers, and finally nursing staff. The initial contact with potential elderly patients was conducted by the first and second authors, who provided comprehensive details about the study and invited participation. Once the patients confirmed their willingness to participate, they signed informed consent forms.

Following the completion of the interviews with elderly patients and confirmation of thematic saturation, the fourth and fifth authors then reached out to eligible caregivers who met the inclusion and exclusion criteria to obtain their informed consent before conducting their interviews. This sequential approach allowed for the exploration of caregivers’ perspectives in relation to the insights gathered from the elderly patients.

Subsequently, after confirming saturation in the caregiver interviews, the sixth and seventh authors identified and secured consent from eligible nursing staff for inclusion in the study.

The evaluation of thematic saturation was conducted through an iterative process of data collection and analysis. Interviews continued until no new themes emerged, ensuring a comprehensive understanding of the subject matter. After each set of interviews, sequential analysis was performed, and data triangulation across patients, caregivers, and nursing staff was employed to ensure the consistent identification of core themes. Furthermore, maximum variation sampling was utilized to include diverse participant characteristics, thereby reinforcing the validity of the findings. Saturation was deemed reached when new participants no longer provided novel insights relevant to the research questions.²¹

Data Collection

We developed an initial interview guide based on a literature review, the Comprehensive Geriatric Assessment (CGA), and group discussions on the physiological, psychological, disease-related, and social characteristics of elderly patients. Pilot interviews with two participants from each study group provided valuable feedback that refined the final interview outline (Table 1).

Table 1 Outline of the Interviews

Three research teams conducted the in-depth interviews, with each team comprising an interviewer and a note-taker. One interviewer managed the conversation, while the note-taker recorded non-verbal cues such as body language and facial expressions. With participants’ consent, all interviews were audio-recorded to ensure accurate capture of the verbal content. Each interviewer received specialized training from experienced researchers at our institution, focusing on effective interview techniques and the study’s objectives to maintain consistency across interviews.

Interviews were conducted in familiar, quiet settings for elderly patients and caregivers, and in a meeting room for nursing staff. Prior to each interview, participants were informed of the study’s purpose and their right to withdraw at any time. All interviews adhered to ethical guidelines, ensuring confidentiality and voluntary participation. Data were anonymized and used solely for research purposes. Each interview lasted 30 to 60 minutes, during which interviewers actively listened, remained neutral, and encouraged participants to share their experiences. Key points were followed up and clarified to ensure accuracy.

Data Analysis

Within 24 hours of each interview, two researchers transcribed the recordings into text, ensuring accuracy by referencing their notes. A third researcher cross-checked these transcriptions, and any uncertainties were clarified with the interviewees to maintain fidelity to their responses. For data analysis, we employed the Colaizzi seven-step analysis method, which consists of the following steps ²² (1) reading all transcripts thoroughly to develop a comprehensive understanding of participants’ experiences; (2) extracting significant statements that highlight key insights, such as the feelings of isolation expressed by elderly patients; (3) coding recurring viewpoints, with isolation being a common theme identified by multiple participants; (4) categorizing these coded viewpoints to reveal overarching themes, such as “psychological support needs”; (5) writing detailed descriptions that incorporate participant quotes, such as “I often feel alone, even when surrounded by family”; (6) identifying nuances within similar viewpoints to enhance the clarity of each theme; and (7) verifying these interpretations with the interviewees to ensure that our findings accurately reflect their lived experiences. For example, a notable theme identified was the psychological support needs of elderly patients, which was consistently emphasized throughout the interviews.

Ethical Considerations

This study was conducted in accordance with the principles of the Helsinki Declaration. Additionally, the study obtained approval from the Ethics Committee of Shanxi Bethune Hospital (No. YXLL-2022-012). Prior to the interviews, all participants signed written informed consent forms. The researchers explicitly explained to the participants their right to withdraw from the study at any time for any reason, as well as the anonymity of the study, ensuring confidentiality throughout the entire research process. The informed consent also included explicit permission for the publication of anonymized responses and/or direct quotes. Importantly, there were no pre-existing relationships or conflicts of interest between the researchers and the participants.

Results

Demographic Characteristics

The analysis of interview data from 10 elderly patients, 5 caregivers, and 5 nurses (a total of 20 participants) revealed largely consistent perspectives on the interview topics, suggesting that data saturation was achieved.

Among the 10 elderly patients, 7 were male and 3 were female, aged between 67 and 85, with an average age of 76.60±5.72 years. Their education levels ranged from 1 with primary education, 6 with junior high school education, 1 with high school education, and 2 with bachelor’s degrees. The average Activities of Daily Living (ADL) score was 76.50±16.84. Of the 5 caregivers, 4 were female and 1 was male, aged between 32 and 86, with an average age of 63.40±24.19 years. Their education included 2 with junior high school education, 1 with high school education, and 2 with bachelor’s degrees. Three were spouses, one was a son, and one was daughter of the elderly patients. The 5 nurses included 4 females and 1 male, aged between 32 and 41, with an average age of 36.40±3.78 years. Detailed demographic information is presented in Table 2.

Table 2 Demographic Characteristics of Interviewees (N=20)

Results of the Interviews

Based on the analysis of the interview transcripts and data, four main themes and twenty-three sub-themes were identified (Table 3). The following sections provide a detailed description of each theme and sub-theme, with “P” representing patients, “C” representing caregivers, and “N” representing nursing staff.

Table 3 Themes and Sub-Themes of Transitional Care Needs for Elderly Patients from Hospital to Home

Theme 1: The Need to Enhance Self-Care Abilities

The Need to Enhance Disease-Related Knowledge

Elderly patients often face multiple chronic conditions, and both they and their caregivers frequently lack the necessary medical knowledge for effective management. This knowledge gap, particularly in chronic disease management, underscores the need to improve understanding of essential health monitoring—such as blood pressure and blood sugar control, medication management, symptom recognition, and when to seek medical help. Enhancing this understanding is vital for promoting their overall health and well-being.

My children weren’t professionals and didn’t know much, but they were eager to learn professional caregiving knowledge to help me. (P7)

Elderly patients with chronic diseases most often asked about blood pressure, blood sugar control, and basic health knowledge. (N2)

The Need to Improve Activities of Daily Living Abilities

As they age and face chronic diseases, elderly patients often experience mobility decline, requiring extra support for daily tasks. These unmet needs hinder their daily functioning, making it vital to improve their ability to perform everyday activities.

Initially, my mother needed help washing her face due to weak arms. After daily exercise, she can wash her face independently but still requires assistance with bathing. She remains eager to be as independent as possible. (C2)

I have encountered many elderly patients with mobility issues who walk slowly and exercise less. Reduced movement leads to a decline in their ability to perform daily activities. (N4)

The Need to Improve Instrumental Activities of Daily Living Abilities

Elderly patients face challenges in daily life, especially with instrumental activities. Physical decline often prevents them from independently performing tasks like cleaning, cooking, or using public transportation, leading to feelings of helplessness. Thus, they urgently seek to improve these abilities to maintain independence.

I could do light cleaning but got tired quickly. My daughter had bought me a robotic vacuum, so I cleaned first and used the robot if needed. (P1)

An elderly stroke patient with mobility issues relied on family to buy necessities and rarely went out. However, he wished he could shop himself. (N4)

The Need to Enhance Disease Management Abilities

Due to limited medical knowledge and skills, elderly patients often struggle to manage their health effectively, relying more on family and healthcare. This affects their prognosis and quality of life, prompting a strong desire to enhance their disease management abilities.

I needed to know how to prevent complications, such as how to protect my feet to prevent diabetic foot. (P2)

Elderly patients were discharged from the hospital with tubes in abundance, but post-discharge tube maintenance, replacement, and more were problematic. (N5)

The Need to Maintain Moderate Physical Activity

Moderate physical activity is crucial for elderly patients to maintain muscle strength, flexibility, cardiovascular health, and control chronic diseases.²³ As a result, they aim to improve their health, quality of life, and delay functional decline through regular exercise.

I experienced occasional knee pain and sought an exercise regimen tailored to my physical condition. (P4)

I was unsure where to start exercising but felt that not doing so would hasten physical decline and muscle atrophy. (P6)

The Need for Daily Safety and Injury Prevention

As elderly patients aged, reduced physical function and mobility increased their risk of falls, prompting them to seek knowledge on creating safer environments and preventing injuries.

Due to leg weakness, my family insisted someone stay nearby to prevent falls, which was inconvenient. (P1)

The elderly stroke patient had limited mobility, with constant fear of falling when left alone. (C4)

Theme 2: The Need for Professional Guidance

The Need for Basic Life Care Guidance

With declining physical and cognitive abilities, elderly patients often needed help with daily tasks like bathing. Some experienced urinary or fecal incontinence, requiring additional care, and sought professional guidance to maintain their health and quality of life.

There was a lack of educational videos on caregiving skills for the elderly. (C3)

Long-term bedridden elderly patients may have needed guidance in turning, sputum management, and pressure ulcer care. (N1)

The Need for Medication Guidance

Many elderly patients had to take multiple medications but struggled to remember the timing and instructions for each, prompting them to seek guidance for effective medication management.

In the morning, I had to take six or seven medications, which was confusing. I worried about side effects from taking them together and wondered if spacing them out would reduce the strain on my liver. (P5)

After managing my blood sugar well in the hospital, I struggled to adjust my insulin dosage at home. I was unsure how to do it safely and feared overdosing or low blood sugar. (P8)

The Need for Dietary Guidance

When elderly patients transitioned from the hospital to home, they had to adjust their diet to match their changing physical condition. They sought personalized dietary guidance to manage their health effectively.

The doctor advised a low-salt, low-fat diet, but I was unsure about the exact amounts of salt and fat I should consume. (P3)

My biggest challenge was balancing nutrients in my cooking, leaving me unsure how to choose the right vegetables and foods. (P7)

The Need for Rehabilitation Guidance

After rehabilitation therapy in the hospital, elderly patients needed to continue exercising at home. However, adapting to a new environment without professional guidance could affect their rehabilitation effectiveness. Therefore, they sought guidance to exercise effectively at home and achieve optimal results.

The nurse provided detailed instructions on rehabilitation exercises at discharge, but after returning home, some of the content was forgotten, hindering the progress of rehabilitation. (P4)

I had limited mobility and needed to continue rehabilitation exercises at home after discharge, hoping for professional guidance. (P6)

Theme 3: The Need for Social and Psychological Support

The Need for Community Living Services

Elderly patients often face declining physical function, social isolation, and inadequate medical support, prompting them to seek accessible community services, such as prepared nutritious meals and opportunities for social engagement, to meet their daily needs and enhance their quality of life.

My primary challenge in daily life was obtaining necessities and preparing food. Group buying with regular community deliveries would have been ideal. (P10)

The community should have organized activities that were beneficial for exercising the elderly. (C1)

The Need for Economic Support

Elderly patients often faced high costs for medical care, rehabilitation, medications, and daily expenses. Reduced income and limited insurance reimbursement increased the financial burden on families. Therefore, they urgently needed economic support, such as improved medical insurance policies, to alleviate financial pressure.

I had spent quite a bit on medical expenses and I was almost unable to cope. (P2)

Some elderly patients had no pension or received a low one, making it difficult for them to support themselves in retirement. (N3)

The Need for Family Support

After discharge, elderly patients might have felt lonely, anxious, and depressed, longing for the company and care of family and friends to provide emotional support, alleviate stress, and boost their confidence and positivity.

My son was very busy with work and had probably not returned home for Chinese New Year for nearly a decade. (P6)

Most children of elderly patients lived elsewhere or abroad, so communication was mainly through phone calls or video chats. This may have left the elderly feeling less cared for and supported. (N5)

The Need for Peer Support

Elderly patients longed for companions who could provide emotional support, share information, motivate and encourage them, promote social engagement, enhance rehabilitation motivation, and help them cope with the challenges of recovery.

By communicating more with fellow patients, they could share their experiences with rehabilitation exercises and ease their fears. (P7)

Thanks to the advice from fellow patients, I was more confident then. (P10)

The Need for Emotional Support

During the transition from hospital to home, elderly patients often faced psychological issues like anxiety, depression, loneliness, and helplessness, along with stress and fatigue from rehabilitation. These challenges created a significant psychological burden. Consequently, they sought to find professional counseling to improve their mental health and coping skills.

There was pressure when one could not care for themselves. (P8)

I felt he was very depressed. He used to be able to move around, but now he had been lying down for about ten days, feeling very uncomfortable (C5)

Desire for Care from Social Groups

Social groups’ care gave emotional support, helped elderly patients form social connections, and boosted their sense of belonging and happiness through activities and volunteer services, promoting their physical and mental health.

During a charity event, a charity organization visited me, chatting, measuring my blood pressure, and helping with cleaning. It was a heartwarming experience. (P7)

The care from social groups made me feel respected and valued, no longer overlooked. (P9)

Desire to Participate in Social Activities

Elderly patients want to participate in social activities, which can provide positive emotional experiences, enhance psychological resilience, and increase life satisfaction. Additionally, the support and encouragement derived from these activities may facilitate better adaptation to family life.

I wanted to chat. I used to enjoy playing chess, but now I need help going out and have no one to play with. (P10)

Elderly patients sought social interaction through cultural and recreational activities, which enriched their lives, increased enjoyment, and fostered friendships. (N2)

Theme 4: The Need for Healthcare Service Resources

The Need for Home Care Services

Elderly patients sought comprehensive home care services to improve their quality of life and recovery. These services included regular medical treatment, rehabilitation, daily living assistance, psychological support, and the establishment of social networks.

We hoped for regular visits from a dedicated nurse, as we greatly needed them. (P8)

Elderly patients expressed the hope of receiving continuous professional nursing care after returning home. I believe that applying the CGA during this process can better identify their issues, leading to improved care services. (N2)

The Need for Professional Services in the Community

Elderly patients hope to receive professional medical services, rehabilitation care, and health education in the community to avoid frequent hospital visits and better address their health needs.

Older patients hoped for direct referrals from community hospitals, with staff or volunteers assisting in the referral process. (P4)

Community hospitals had specialized doctors to address minor health issues. (C5)

We could collaborate with the community to provide professional care for the elderly. (N3)

Desire for Accessible Professional Rehabilitation Institutions

Elderly patients wanted easy access to professional rehabilitation services. Experienced rehabilitation experts could create personalized, comprehensive plans to meet their needs.

I couldn’t find any professional rehabilitation facilities nearby; most were massage parlors. After a few exercise sessions, I realized they weren’t professional. (P5)

After discharge, patients needed a place for follow-up rehabilitation, but not all prefecture-level hospitals had rehabilitation departments. (N1)

Desire for Efficient Emergency Medical Rescue

Elderly patients desired prompt, high-quality medical care from the medical team to address potential emergencies such as heart attacks or strokes, which would boost their confidence during the transition period.

One night, my spouse had a heart attack. After taking medication without relief, we couldn’t reach the community hotline. When we called 120, they said, ‘I’m sorry, all ambulances were dispatched. We sought other resources to assist you quickly.’ (C4)

Elderly individuals with sudden illnesses at night were often hard to detect, and professionals did not arrive quickly, causing delayed treatment. Family members, lacking emergency response knowledge, often felt anxious and helpless. (N3)

Desire for Convenient Medical Services

Elderly patients hoped for more convenient, personalized, and efficient services from medical institutions, including optimizing the consultation process, improving the medical environment, and enhancing service attitudes to make visits more accessible.

Elderly patients found it difficult to go to the hospital due to mobility issues with their legs. (C3)

Many family members expressed that taking elderly patients for follow-up check-ups was inconvenient and required a thorough understanding of hospital procedures, which could be quite exhausting. (N2)

Desire for Convenient Doctor-Patient Communication Channels

Elderly patients faced mobility challenges, making it difficult for them to visit hospitals. Therefore, they hoped for easier access to doctors’ advice through convenient communication channels, reducing the need for multiple trips and unnecessary anxiety.

Various communication channels, including telephone contact, were established to facilitate timely consultations with medical staff for issues arising outside the hospital. (C5)

Patients and their family members could use internet platforms for easy communication with us at any time. (N4)

Discussion

Our study reveals that the care needs of elderly patients transitioning from hospital to home is distinctly multidimensional, significantly differing from their regular care needs. Transitional care must address not only medical and physical conditions but also enhance psychological security, professional guidance, and integrated support services. In contrast, standard care primarily focuses on chronic disease management and maintaining daily routines, often neglecting the immediate complexities encountered post-discharge. Elderly patients are particularly vulnerable during this transition due to the abrupt shift from hospital-based care to home environments, where professional support is often insufficient or fragmented. This heightened vulnerability underscores the necessity for comprehensive interventions that address both medical and non-medical challenges, which are typically underemphasized in standard care models, aligning with findings by Kiran et al ²⁴ Our results emphasize the importance of targeting these transitional-specific needs, especially within the Chinese healthcare system, where resources are predominantly hospital-centric and home care services are limited. This study fills a critical gap in understanding the disparities between transitional care needs and standard geriatric care, thus contributing to the literature on improving care continuity for elderly patients. In the following sections, we will discuss this in four specific aspects based on our findings.

Using the Comprehensive Geriatric Assessment(GCA) to Identify Various Nursing Issues Among Elderly Patients

In this study, elderly patients indicated that they often face various nursing challenges in daily care, medication, diet, and rehabilitation after transitioning from the hospital to home. Families are unable to effectively manage these issues and urgently require professional guidance. However, the presentation of these health problems is mostly based on the elderly patients’ personal experiences and perceptions, which necessitate further assessment by medical personnel to ensure accuracy. Nursing staff noted that the needs of elderly patients for improvements in physical function, rehabilitation guidance, and psychological counseling are frequently overlooked, with the current focus primarily on disease management and symptom control. This reliance on clinical experience often neglects critical aspects of cognitive, mental, and social health. Research supports that CGA effectively evaluates multiple dimensions of health in elderly patients, including physical function, mental health, and social support systems.²⁵ It identifies existing and potential health issues while screening for risk factors that may negatively affect disease prognosis and increase mortality rates.²⁵ Early detection of multidimensional health problems through CGA allows elderly patients to receive timely and comprehensive interventions, thereby improving overall health outcomes. For healthcare providers, CGA facilitates the accurate identification of health issues, enabling the development of evidence-based discharge plans. This approach promotes interdisciplinary collaboration and efficient resource allocation, ultimately improving the quality of transitional care. Given these findings, it is recommended to integrate CGA into the discharge planning process for elderly patients transitioning from hospital to home, ensuring comprehensive care and improving the continuity of care for these patients.

Systematic Health Education Enhances Self-Care Abilities in Elderly Patients

During the interviews, participants expressed a desire to enhance their self-care abilities in various aspects such as disease-related knowledge, daily living activities, instrumental activities of daily living, disease management, and daily safety and risk prevention. This is similar to the findings of Dolu et al ¹³ Good self-care abilities can help elderly patients better manage their health, reduce complications, and improve their quality of life. Conversely, elderly patients with poor self-care abilities may require more external support and care, and are more likely to experience psychological and social issues.²⁶ Although many elderly patients have some self-care abilities and willingness, their self-care abilities often cannot meet the demand when their health is threatened, mainly due to insufficient autonomy in obtaining health information and lack of external resources. This highlights the need for healthcare professionals to continuously improve the content and format of health education during the hospital-to-home transition period, and to systemically disseminate health knowledge. Additionally, establishing accessible medical consultation and educational channels for patients is crucial to ensuring the long-term sustainability of health promotion. Empowerment education is an education process based on empowerment. Healthcare professionals assess the patient’s current situation, collaborate with the patient’s preferences, and jointly develop a care plan to help patients build health awareness and master health skills. Guo et al stated that implementing empowerment education not only deepens elderly patients’ understanding of disease-related knowledge but also enables them to fully utilize internal and external resources to address new issues, significantly enhancing their self-care abilities.²⁷ Given these insights, it is recommended that healthcare professionals incorporate empowerment education into transitional care for elderly patients. This should involve exploring diverse educational models aimed at enhancing patients’ health awareness, knowledge, and nursing skills.

Family and Social Support Meet the Mental and Psychological Needs of Elderly Patients

Due to chronic and comorbid conditions, elderly patients and their families face heavy caregiving and financial burdens, including medical, medication, rehabilitation, nursing, and daily living expenses. Repeated hospitalizations can lead to fatigue, guilt, self-denial, fear, anxiety, depression, and other psychological disorders among elderly patients. This is consistent with previous studies; when environmental and social-psychological needs are not met, it can affect patients’ self-management and recovery at home after discharge.²⁸ Therefore, community or hospital nursing staff need to observe and assess the mental health of elderly patients during each professional guidance session, intervene in a timely manner based on the assessment results to prevent the development of negative emotions. Understanding and emotional communication from family members can help elderly patients relieve inner pressure and anxiety, promote mental health, while encouragement and support can enhance their confidence in overcoming illness, helping them to actively face treatment and recovery. Given these insights, healthcare professionals should encourage family members to engage with elderly patients through chatting, gatherings, and outdoor activities to alleviate psychological stress and promote recovery. Fostering hobbies and community participation can also enhance their social and spiritual well-being. Community volunteers can provide valuable services, such as haircuts and home repairs, reinforcing feelings of care. Establishing WeChat groups or patient forums can facilitate communication, helping to reduce isolation and build confidence. For patients with psychological disorders, timely mental health interventions are essential. In summary, a comprehensive approach that combines family support, community engagement, and professional mental health care is vital for enhancing the psychological well-being of elderly patients and improving recovery outcomes.

Improving the Quality of Transitional Care Services for Elderly Patients Through Discharge Preparation

In the study, elderly patients expressed the need for professional guidance in disease management, nutrition, medication, functional improvement, and safety management, as well as continuous home medical care services. These findings resonate with existing literature, which indicates that elderly patients often face fragmented care and a lack of psychological security during the transition from hospital to home.²⁹ Such challenges highlight the urgent requirement for comprehensive medical, nursing, psychological, and social support systems to ensure the continuity and safety of care. Discharge preparation services refer to the process and services through which patients transition from the hospital to home, community, or facility care.³⁰ Scientifically preparing a discharge plan can reduce readmission rates, improve quality of life, and lower medical costs, ensuring that patients safely transition from one care stage to the next.³⁰ Based on these findings, it is recommended that healthcare professionals implement multidisciplinary discharge preparation services, starting from admission and extending through post-discharge care. This approach should involve collaboration among doctors, nurses, dietitians, and rehabilitation therapists to ensure tailored care that aligns with patients’ needs and family preferences. Continuous follow-ups, guidance, and evaluations can enhance elderly patients’ health outcomes. The service timeline covers the entire care process, aiming to prevent fragmented care. Future research should explore how these models improve care coordination during transitions from hospital to home.

Collaboration Across Departments to Ensure the Accessibility of Healthcare Resources for Elderly Patients

Elderly people have long-term and complex care needs. In this study, elderly patients expressed a desire for regular medical observation, treatment, and professional rehabilitation care at home or in the community. This finding aligns with existing research that highlights the complexity of elderly care, particularly in ensuring continuity of care at home.³¹ Moreover, the emphasis on receiving efficient medical assistance in emergencies mirrors prior studies emphasizing rapid, quality care for older adults.³¹ In China, due to limited nursing resources, hospitals focus more on providing inpatient services, leading to a need for further improvement in the content and quality of continuing care services during the transition from hospital to home and after discharge. Based on these findings, it is recommended that hospitals enhance their organizational structures by establishing nurse-led multidisciplinary teams to provide continuous, individualized care for elderly patients during transition periods. Additionally, promoting medical technology and developing internet hospitals will enable home-bound patients to access online consultations, significantly improving care efficiency. Introducing internet-based home care services will ensure professionalism and continuity of care. Furthermore, decentralizing medical resources and fostering collaboration between large hospitals and community facilities are vital for optimizing care delivery. Strengthening grassroots medical staff’s capabilities will better meet patients’ daily needs. Large comprehensive hospitals should promote an elderly-friendly culture, enhance their diagnosis and treatment of age-related conditions, and establish green channels for quicker access to outpatient and inpatient services. Finally, reforms in the medical insurance system are essential to ensure elderly patients’ financial security, particularly by enhancing the reimbursement ratio and coverage of medical expenses. This coordinated approach will ultimately improve accessibility to necessary medical and nursing services for the elderly population.

Limitations

This study has several limitations. Firstly, while it aimed to comprehensively understand the needs of elderly patients from various stakeholders’ perspectives, it conducted only one round of interviews, which may not capture the evolving nature of needs during the transitional care process. Future research should consider longitudinal studies to explore these needs and experiences over time. Secondly, the study was conducted at a single hospital, which may limit the generalizability of the findings. Lastly, the sample size was limited; future research should aim to conduct multicenter studies employing both qualitative and quantitative methods to validate the conclusions and enhance generalizability across diverse populations.

Conclusion

This study examined the transitional care needs of elderly patients moving from hospital to home, identifying four key themes: the need for enhanced self-care abilities, the need for professional guidance, the need for social and psychological support, and the need for healthcare service resources. These findings underscore the diverse and multidimensional nature of needs during this transition. To address these needs, healthcare professionals should conduct comprehensive assessments during patients’ hospitalization, accurately identifying care issues and implementing team-based interventions. By fulfilling these needs, healthcare providers can ensure that elderly patients are well-prepared psychologically, possess sufficient knowledge and self-care skills, and have access to comprehensive support services from hospitals and communities as they transition from professional hospital care to home self-care. These findings provide essential insights for improving transitional care and effectively guide clinical practice.