Navigating outpatient care of patients with type 2 diabetes after hospital discharge - a qualitative longitudinal study

Background The transition from hospital to outpatient care is a particularly vulnerable period for patients as they move from regular health monitoring to self-management. This study aimed to map and investigate the journey of patients with polymorbidities, including type 2 diabetes (T2D), in the 2 months following hospital discharge and examine patients’ encounters with healthcare professionals (HCPs). Methods Patients discharged with T2D and at least two other comorbidities were recruited during hospitalization. This qualitative longitudinal study consisted of four semi-structured interviews per participant conducted from discharge up to 2 months after discharge. The interviews were based on a guide, transcribed verbatim, and thematically analyzed. Patient journeys through the healthcare system were represented using the patient journey mapping methodology. Results Seventy-five interviews with 21 participants were conducted from October 2020 to July 2021. The participants had a median of 11 encounters (min–max: 6–28) with HCPs. The patient journey was categorized into six key steps: hospitalization, discharge, dispensing prescribed medications by the community pharmacist, follow-up calls, the first medical appointment, and outpatient care. Conclusions The outpatient journey in the 2 months following discharge is a complex and adaptive process. Despite the active role of numerous HCPs, navigation in outpatient care after discharge relies heavily on the involvement and responsibilities of patients. Preparation for discharge, post-hospitalization follow-up, and the first visit to the pharmacy and general practitioner are key moments for carefully considering patient care. Our findings underline the need for clarified roles and a standardized approach to discharge planning and post-discharge care in partnership with patients, family caregivers, and all stakeholders involved.</p

Additional file 1 of Navigating outpatient care of patients with type 2 diabetes after hospital discharge - a qualitative longitudinal study

Additional file 1. Interview guides

Transition hôpital-ambulatoire : les enjeux pour les patients avec un diabète sucré

La transition entre l'hôpital et l'ambulatoire est une période à risque pour les patients avec un diabète sucrée et un enjeu pour les professionnels de la santé. Différentes interventions en collaboration interprofessionnelle ont montré un impact positif sur la continuité des soins à la sortie de l'hôpital. La communication et la transmission d'informations entre les milieux hospitalier et ambulatoire ainsi qu'une coordination entre les professionnels de la santé sont des points clés à explorer et à continuer d'améliorer pour garantir une continuité des soins optimale.The transition from hospital to ambulatory care is a high-risk period for patients with diabetes mellitus and is a challenge for health care professionals. Various interprofessional collaborative interventions have shown a positive impact on continuity of care at discharge. Communication and transmission of information between the hospital and ambulatory settings as well as coordination between healthcare professionals are key points to explore and to improve to ensure optimal continuity of care