Wanling Li,1,2,* Shufang Shi,2,* Yajie Shi,2 Xiaofang Feng,2 Yueqin Li,2 Yuli Guo,2 Jiajia Xu,2 Liping Cui,2 Mei Wang1 

1Department of Comprehensive Medical, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China; 2Department of Nursing, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Tongji Shanxi Hospital, Taiyuan, 030032, People’s Republic of China

*These authors contributed equally to this work

Correspondence: Mei Wang, Department of Comprehensive Medical, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei, 430030, People’s Republic of China, Tel/Fax +86-0351-8379512, Email wm69520@126.com Liping Cui, Department of Nursing, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Tongji Shanxi Hospital, 99 Longcheng Street, Taiyuan, Shanxi, 030032, People’s Republic of China, Tel/Fax +86-13934154909, Email sxtylsj-1@163.com

Background: Elderly patients, due to their complex medical conditions and extensive care needs, are at risk of experiencing low-quality or fragmented care during transitions between different healthcare settings. After transitioning from hospital to home, inadequate self-care abilities may result in further health deterioration and increased risks of adverse outcomes. Currently, China lacks effective transitional support services from hospital to home, hindering the smooth transition for elderly patients. Therefore, understanding the specific care needs of elderly patients during this period provides a scientific basis for establishing reasonable transitional support services.
Objective: This study aims to explore the transitional care needs of elderly patients during the hospital-to-home transition, as perceived by key stakeholders—patients, caregivers, and nurses—using Shanxi Province as a case example.
Methods: A descriptive phenomenological method was employed in this study. Purposeful sampling selected 10 elderly patients, 5 caregivers, and 5 nursing staff from a tertiary hospital in Shanxi Province, China, for semi-structured in-depth interviews. The Colaizzi’s analysis was used in data analysis.
Results: The transitional care needs of elderly patients from hospital to home can be summarized into four themes: the need to enhance self-care abilities, the need for professional guidance, the need for social and psychological support, and the need for healthcare service resources.
Conclusion: Elderly patients have diverse care needs during the hospital-to-home transition, which require urgent attention and support. To address these needs, healthcare professionals should conduct comprehensive assessments during the 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.

Keywords: elderly patients, transitional care, needs, stakeholders, qualitative study