Table 4:

Patient and caregiver views on factors affecting the experience of transitioning from hospital to home: medical follow-up after discharge

Unique conceptRepresentative quote*
Timely follow-up with family doctor, nurse practitioner or specialistMy family doctor, who is a member of [primary care organization], called to arrange a follow-up appointment. (Female patient, age 50–64)
My family doctor knew my daughter was admitted to hospital because I phoned to let her know. I knew that, if we ran into trouble after discharge, our doctor would fit us in to be seen. (Caregiver of female patient, age ≤ 5)
Told to call [the doctor’s] office (which was stated on a form they gave me) in 6 weeks. When I called, the nurse laughed and said [the doctor] hadn’t seen patients that he had operated on for more than 6 months prior to my operation. I kept calling, and it took over a year to see him. (Female patient, age 65–79)
Having a trusted family physicianNo attempt to connect me with a family physician was made by [hospital]. (Male patient, age 65–79)
I had a trusted family doctor that I could consult if I was uncertain about anything. (Female patient, age 50–64)
Having specialist follow-up arranged or being able to arrange itDischarge summary listed 2 critical follow-ups needed within 1 week: cardiology and nephrology clinics — NEITHER appointment was made when we left hospital. (Female patient, age 50–64)
Clear, concise written instructions for follow-up appointments with various doctors were given, so that was a handy guide. (Female patient, age 65–79)
Family physician receives complete and timely information about hospital admissionI wish that my primary care physician had received notification about my [hospital admission]. When I phoned about constipation issues and the bed sore, they had no idea what had happened or care that had been provided in the hospital and would have liked to have been more proactive on these issues. (Female patient, age 26–49)
Family doctor received nothing from hospital to allow a seamless transition home. (Caregiver of female patient, age 65–79)
Information transfer between facilitiesLack of transitional support for journey from home to hospital to retirement home which was a bridge to long-term care. Information transfer was lacking at each stage, so needs were not able to be met initially at each stage. A case manager seemed to be lacking. (Female patient, age 50–64)
Detailed notes and test results were sent to the [rehabilitation] hospital. (Caregiver of female patient, age ≥ 80)
Challenges getting to and from appointments once dischargedRoutine visits to clinic were very difficult post stroke but were not offered through telemedicine. (Caregiver of female patient, age ≥ 80)
Having to follow up with a doctor whose office was out of town and I do not drive. (Female patient, age 26–49)
The hospital parking for follow-up was poor. The garage with elevators and easy access is reserved for staff. It’s not just the cost of parking — it’s also the ease of use. (Female patient, age 65–79)
Having a doctor who does home visitsFamily doc doesn’t make house calls, so totally lost contact with a doctor. How can a person in bed with discomfort in a wheelchair get an assessment from a doctor? Totally a huge logistical challenge and exhausting and painful for patient to use wheelchair taxi to go to physician office. (Caregiver of person age ≥ 80)
  • * Respondent age and gender are provided when available; caregiver respondents provided the age and gender of the patient they were caring for.