Table 3 Barriers and Solutions to transferring older patients from tertiary-care to community-based healthcare system

Patient Factors

Patient-centered communication

(Incomprehension of the healthcare system)

“There are many cases where patients believe that if they want to remain admitted, they could stay as long as they want in tertiary hospitals.”

“They think transfer-out as an alternative to the difficulty of admission to a tertiary hospital. Some older patients wait for days at the ED for admission.”

“Older patients do not have a good understanding of the healthcare system, especially they do not recognize that the functions of secondary or convalescent hospitals are different from those of advanced general hospitals. Dislike, resistance, or negative emotions are the first obstacles encountered when we decide or recommend transferring older patients to another hospital.”

“It is important to have sufficient communication about the treatment direction between the hospitals and the older patients or decision-makers.”

“Necessary to form a consensus that tertiary hospital healthcare is no longer needed and provide promising continuity and integration of medical treatment through referrals.”

Lack of communication with caregivers or decision-makers

“Caregivers do not receive sufficient explanation about treatment direction”

“When older patients are transferred into our palliative care wards, they often come without knowing what palliative care is. Therefore, a lot of times they want more active treatment”

“Prior to transfer, we need a consultation with the patients or caregivers. Therefore, we can reassure the treatment directions as well as the education for upcoming facilities.”

“Multidisciplinary approach is needed to bring together a group of healthcare professionals from different fields within the institution, including nurses, social workers, public health cooperation managers, and doctors.”

Socioeconomic status

“Decision-making based on economic factors rather than medical factors causes another side effect.”

“I have seen many older patients who do not want to be transferred out to higher-level hospitals because they would experience a much greater financial burden.”

“A transition care plan needs to be built in consideration of socioeconomic factors because of expensive caregiver fees, and to clearly outline how much the families or older patients are willing to pay for the facilities.”

Patient Perception

“Older patients with high anxiety do not accept that the current tertiary hospital treatment is no longer necessary.”

“Prior experience of long ED stays or decline of admission due to lack of inpatients bed availability developed anxiety among older patients regarding the process of readmission in the future for possible clinical deterioration.”

“In order to relieve the anxiety of patients and their caregivers, a system that guarantees the continuity and integrity of treatment is required.”

“Reinforcement of supportive care through patient-centered remarks in the medical records, medical referrals, and public medical teams was necessary.”

Institutional Factors

Different Fee structure

“Each medical institution provides a different pricing system. Tertiary teaching hospitals adopt a fee-for-service payment model. However, secondary general hospitals and public healthcare are based on DRG payment to all patients.”

“We cannot apply the identical prescriptions received from tertiary level hospitals. Patients complain and it hinders consistency and integrated treatment.”

“In convalescent hospitals, a transient fee-for-service scheme for transferred patients from upper-tier hospitals might be beneficial for more appropriate subacute care and rehabilitation.”

“More rational fee schemes for older patients with varying medical- and functional care needs are needed.”

Barriers to accessing health service in tertiary hospitals/ Referrals

“It is really difficult to refer older patients back to tertiary care other than for emergency situations because of an inadequate number of hospitals [tertiary hospital] beds. Patients wait for days in the ED.”

“Better systems than the current phone call- or written note-based transfer inquiry model are required. Systems or routes to expedite reverse-transferring older patients who were recently transferred from tertiary level care, require higher-level treatment with deteriorating conditions in secondary hospitals or convalescent hospitals.”

“Easy and usable ways of communications between doctors are needed.”

Insufficient cooperation and mutual communication between institutions

“When I refer a patient with a catheter, I need to know if the hospital is capable of managing such conditions.”

“If I am referring a cancer patient who is on chemotherapy, I need to know transparently whether there is an oncologist who can manage the patient.”

“Transparent information disclosure between institutions and standardized information management is required but it is difficult to know this when we transfer our patients.”

“Important medical information is intentionally omitted. This leads to breaking the trust of the medical cooperation system.”

“Basically, there is a difference in medical philosophy.”

“Residents at the university hospital miss critical information in the patients’ medical records regarding what patients might need when they are transferred.”

“After transferring the patients, no one follows up on what happened to the patient.”

“Transparent communication between physicians and educational institutions (including residents) to facilitate better communication.”

“Standard formats and checklists in transfer or discharge records should be developed.”

“Case management for patients with care transitions, on post-transfer issues.”

“Opportunities to communicate with healthcare personnel in different care settings are needed to understand each other”

Need for subacute rehabilitation treatment services

“After the acute phase, patients often need rehabilitation. However, it is tough to transfer patients to legitimate rehabilitation facilities because we face a rehabilitation facility shortage

“Rehabilitation is often undertaken in long-term nursing facilities, which reduces the quality of rehabilitation treatment itself.”

“Subacute care model for acutely admitted patients with complex care needs should be developed and implemented.”

“More rehabilitation hospitals are needed. Otherwise, long-term hospitals (convalescent hospitals) should provide more patient-specific post-acute care, upgrading from the current minimal support for basic medical needs.”