Graduation Date

Spring 5-7-2016

Document Type


Degree Name

Doctor of Philosophy (PhD)



First Advisor

Karen L. Schumacher, PhD

Second Advisor

Sarah Thompson, PhD


Research studies on care transitions from hospital to nursing home are few and heterogeneous, offering an inadequate characterization to support practice. The purpose of this study was to characterize multiple care transitions among hospitalized older adults with advanced chronic disease who were discharged to a nursing home. This prospective, mixed methods study used multiple case studies with an embedded quantitative strand and multiple sources of information.

Four cases included an index patient (an older hospitalized adult with advanced chronic illness), his or her informal caregiver, if available, and healthcare providers involved in the index patient’s care. Two hospitals and two nursing homes participated. Healthcare providers, expert in care transitions within those facilities, were interviewed for facility context.

Care transitions occurred in two contexts: the facilities’ organizational context and the patients’ ongoing life transitions. While care transitions were time-bounded healthcare provider-centered processes, life transitions were ongoing and principal-centered. Defined care transition processes were complicated. However, dynamic interactions between patients, family caregivers, and healthcare providers occurred in multiple complex systems. Dynamic interactions within the complex systems were affected by the alignment of the familial approach to patient support with the patient’s needs and the availability of a stable core. Symptom distress and quality of life trajectories did not illuminate differences in principal experiences. However, patterns of dynamic interactions were different between patients experiencing unplanned utilization and those who did not.

Fragmented processes and lack of feedback loops were the norm. This fragmentation limited information flow. Simple outcome measures did not reflect the complexity of care transitions. While quality of life measures and symptom distress did reflect the patients’ situation at a moment in time, they did little to explain the patient’s experience of care transitions.

Implications for practice relate to the complexity within care transitions. Limited information flow due to role fragmentation and lack of feedback loops hamper learning and adaptation both within individual cases and across facilities. Care transitions from hospital to skilled nursing facility occurred within complex systems. As such, future research must consider not only the processes, but also the relationships and dynamic interactions within the systems.