Table 3.

Themes and Illustrative Quotes: Continuity of Care

Continuity of Care and Communication on Care Transitions
Communication with multiple providers:  “Because the patient may be seeing multiple doctors that’s prescribing different medications…. So you don’t know which medication the patient should be taking. So you have to call three or four doctors to clarify that” [FG1]  “that’s where you have to call the Cardiologist for the Cardiac Meds, the Nephrologist’ for some the meds. The Neurologist with the pain meds ….. you know you could be looking in three different spots and you still may not find that was their problem.” [FG5]  “You know, one thing I noticed is that they put the hospitalist’s name, they don’t list the cardiologist, they don’t list the PCP. So you have to look through. Okay so who is your doctor? “Doctor Hernandez” and who’s your cardiologist? “I don’t know” It’s incomplete with the most vital information which is the doctor’s.” [FG4]  “PCP, cardiologist, arrhythmia doctor, and all three are prescribing. And I’m like, okay, so which one? And no one knows anything.” [FG4]
Discharge documentation:  “Nurse 1: And then you have to look through that thick book of discharge papers and they’re in English ---   Nurse 2: I don’t know what that is and the majority of our patients are Hispanics and some of them, they don’t know how to read.” [FG4]  “we would need to know current medications that the patient is taking and which ones are from the past that they should not be taking. That’s what we need to know because the patient might not know and the hospital discharge is not very clear.” [FG2]  “we check it all the time because a few times I saw the discharge papers were another person instead of the patient. At least two times I had it and because I see his medications at home and are completely different medications. It’s a completely different person.” [FG2]  “we’re checking the discharge papers and what not, but is there any like further with the heart medications they’re not always accurate from the hospital.” [FG5]
Communicating with doctors:  “A lot of the doctor’s offices have these secretaries and they don’t know anything about terminology. No medical knowledge at all, so when you’re telling the secretary something...it’s like...they don’t understand the importance of the message that you’re leaving.” [FG1]  “It’s wonderful that we make a call and we tell the doctor, “Doctor, this patient gained a pound, or two pounds”. It would be nice if they called you back. That is the main thing because what is the use of us coming in there, making all this wonderful assessment, putting on the notes, making the calls, and you don’t get that call back. So, one or two days later, in the meantime, because it’s heart failure patient, we’re sending him to a walk-in clinic to have the Lasix adjusted.” [FG4]  “Exactly, because most of the time, we are in the field trying to reach the doctor patient, weight increase, five or more pounds. We cannot get a hold of the doctor, we have to call 911.” [FG3]  “If they are on Coumadin their dose can vary very frequently and we don’t always have it updated in the plan of care because the doctor’s office is calling them to update and we don’t know it was updated three day ago and now we have lab work again” [FG5]  “would be great if they would give us like a standard order say if three pounds in one day do X, Y, Z or…” [FG3]
Maintaining continuity during a home care episode
Tracking signs and symptoms:  “Especially weight is the biggest thing with heart failing patients. If their weight is more than three pounds from one day to the next then that’s a problem. If it’s more than five pounds in one week, that’s a problem.” [FG2]  “Nurse 1: I have a patient you know that I have met yesterday, she’s heart failure but she weighs 300 pounds  Nurse 3: So we have a problem with that getting scales for those patients that are above 350.” [FG1]  “Those are usually the most obvious signs, between the lungs and weight. Those are the two biggest indicators or at least the most visible that you can see, quickly, and that’s the key to catch any changes early.” [FG5]  “If it’s not written down like if there isn’t someone there weighing and you can say “Okay, do you have a log? Can we see the log?” because sometimes they keep logs, sometimes they don’t. It’s us if we’re go in. If you can’t physically see a log then you have to rely on backtracking through notes.” [FG5]  “most of at least my CHF patients, you know, are taught how to keep a log…of their weight and whatever is needed, their blood pressures and finger sticks and everything.” [FG3]  “If the patient goes [outside the range] of the parameter then you have a red flag” [FG6]
Patient Teaching:  “Diet, exercise, medication, following the whole plan… if we have an idea of whether or not they’re aware or their education level regarding these items then we can know how we’re going to educate them.” [FG1]  “if you have an idea of what they have been educated on consistently, than perhaps you can either pick up from where the other person’s left off or maybe identify some other deficit that you can address” [FG1]  “It has to be.... the whole deal. Diet, exercise, medication, following the whole plan. And so if we have an idea of whether or not they’re aware or their education level regarding these items then we can know how we’re going to educate them.” [FG2]  “Are they able to retain what we’ve already taught them, are we just being redundantly teaching them the same thing over and over and they’re never going to learn that concept” [FG5]  “at start of care it gives you a baseline and it gives you a sense of knowledge to which way you expect the patient to go and how to plan your care and how to – and how to provide teaching.”[FG3]  “teaching the patient though. We’re not going to be here forever. You have to know, if you gain three pounds over night or five pounds, you need to call the doctor and they need to give you the water pill.” [FG6]