Despite patient safety initiatives to improve care transitions, prior research largely neglects to elicit feedback from home health nurses regarding health information exchange. The goal of this quality improvement study was to identify opportunities to facilitate information transfer during hospital-to-home-health-care transitions for older adults with heart failure. We conducted focus groups with 19 nurses employed by a single healthcare system using two commercially available electronic health record (EHR) vendors. We analyzed interview transcripts following an immersion/crystallization approach to identify themes. Average participants were females in their mid-fifties with 15 years of home health experience. Nurses reported challenges with hospital-to-home-health-care information exchange, specifically: 1) poor medication management, 2) ineffective communication, 3) technology issues, and 4) patient factors. Nurses identified several opportunities for improvement, including discordant EHR-generated medication lists, which may be amenable to technological solutions. Local quality improvement efforts should incorporate nurses' suggestions and leverage existing best practices.
Keywords: Care transitions; Health information exchange; Heart failure; Medication management; Skilled home health care.
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