Older adults’ and relatives’ experiences of a cross-sectoral home-based follow-up visit after hospital discharge

Background: Older adults living with multimorbidity often require coordinated involvement from multiple stakeholders to ensure continuity and safety when transitioning from hospital to home. Hence, such transitions frequently remain fragmented, leaving patients and their relatives uncertain and vulnerable. This study explores how older adults and their family members experienced a nurse-led, cross-sectoral, home-based follow-up visit conducted jointly by a hospital-based nurse and a primary care nurse after discharge from a geriatric department.

 

Approach: Embedded within a randomised controlled trial, this qualitative study was grounded in critical psychology practice research. Semi-structured interviews were conducted with 10 older adults and 6 relatives (3 spouses and 3 adult children), either face-to-face or by telephone. To enrich contextual understanding, field observations at home, during the interviews, were also undertaken. Data were analysed using the critical psychology framework of conditions, meanings, and reasons, exploring how participants made sense of and reasoned their experiences.

 

Results: Three key themes emerged: (1) The cross-sectoral home-based follow-up visit was experienced as caring and competent nursing support, participants experienced the joint visit as a reassuring and feelings of being seen and cared for; (2) Navigating dependency and disruption involved balancing a new life situation, older adults described balancing vulnerability and independence in a changed life situation; (3) Relatives felt caught between providing support and experiencing caregiver burden, family members expressed both gratitude for professional involvement and the emotional challenges of caregiving.

 

 

 

Implications: The nurse-led, cross-sectoral home visit fostered safety, trust, and partnership by bridging hospital and primary care. Integrated professional collaboration enhanced communication, ensured shared understanding, and supported older adults’ recovery and autonomy at home. Findings demonstrate how involving older adults and their families as active participants in care can strengthen continuity, promote wellbeing, decrease older adults' experience of vulnerability and advance integrated care.