| Summary: | Across the Western world, healthcare services are contending with the challenge of ageing populations. Switzerland is no exception, and faces the need to adapt its healthcare system to the needs of older persons. A disease-oriented approach is ill suited to the varied abilities, preferences and degrees of resilience among older people, and person-centred care is better placed to respond effectively to this situation (Ekman et al., 2013). Our team at the Institute of Higher Education and Research in Healthcare (IUFRS) of the University of Lausanne has developed a research programme to improve the healthcare experiences of older persons during hospitalisation and transition to discharge. We have identified different models and theories that promote a better understanding of the factors that impact on older persons ’lives during these phases and of how to take them into account in nursing practice in order to encourage a person-centred approach.
The transition of care from hospital to home is a vulnerable time in the continuum of care for older persons (Arbaje et al., 2014). Transitional care is defined by Coleman and Boult (2003, p 549) as a ‘set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location’. At the theoretical level, Meleis ’transitions theory (2000) provides a perspective for interpreting and planning comprehensive discharge for hospitalised older persons. In designing our research programme, this theory helped us to link the older person’s health problems (conditions of transition) in relation to hospitalisation (nature of transition), discharge preparation (nursing interventions) and the effects on the person (response models) (Mabire et al., 2015). From the transitions theory, Naylor et al. (2017) developed their transitional care model to guide nursing practice during this period. This model includes eight components:
Patient engagement
Caregiver engagement
Complexity and medication management
Patient education
Caregiver education
Patient and caregiver wellbeing
Care continuity
Accountability
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