Experiences of elderly patients regarding independent community living after discharge from hospital: a longitudinal study.

Objective: To describe the reported experiences of elderly patients regarding their transition from an acute hospital to independent community living.
Design: Observational longitudinal study based on semi-structured interviews conducted monthly for 6 months following discharge from hospital.
Setting: Four South Australian acute hospitals. Patients. One hundred elderly patients who faced a long-term change in health status and/or in their ability to manage practical aspects of daily living.
Main Outcome Measures: Experiences in managing change in health status, social circumstances and independent community living.
Results: Few patients believed that discharge plans made in hospital had assisted their return to independent community living. Discharge planning addressed mainly formal health services rather than practical aspects of daily living. Many patients implemented innovative solutions when formal services were unavailable or inadequate. Pain, tiredness, loss of mobility, and grief over loss of previous abilities were frequent, long lasting sequelae to illness, and few discharge plans prepared patients to deal with this.
Conclusions: Elderly patients who have left hospital to face a permanent change in health status often regret that they have not been better prepared for what lies ahead in terms of more specific information about their condition, linked with practical discharge plans that prepare them for their period of convalescence. We suggest that the underlying problem is a disjunction between the multiple systems involved in hospital discharge planning, primary medical care, disability-oriented community health services, and informal community services.