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BConnecting the Dots^: A Qualitative Study of Home Health
Nurse Perspectives on Coordinating Care for Recently
Discharged Patients

Christine D. Jones, MD, MS1,2, Jacqueline Jones, PhD, RN, FAAN3, Angela Richard, PhD, RN3,4,
Kathryn Bowles, PhD, RN, FAAN, FACMI5,6, Dana Lahoff, LCSW7, Rebecca S. Boxer, MD, MS7,
Frederick A. Masoudi, MD, MSPH8, Eric A. Coleman, MD, MPH4, and Heidi L. Wald, MD, MSPH1,4

1Hospital Medicine Section, Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; 2University of
Colorado Denver School of Medicine, Hospital Medicine Division, Aurora, CO, USA; 3College of Nursing, University of Colorado Anschutz Medical
Campus, Aurora, CO, USA; 4Division of Health Care Policy and Research, University of Colorado Anschutz Medical Campus, Aurora, CO, USA;
5School of Nursing, University of Pennsylvania, Philadelphia, PA, USA; 6Visiting Nurse Service of New York, New York, NY, USA; 7Division of Geriatric
Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; 8Division of Cardiology, University of Colorado Anschutz Medical
Campus, Aurora, CO, USA.

BACKGROUND: In 2012, nearly one-third of adults
65 years or older with Medicare discharged to home after
hospitalization were referred for home health care (HHC)
services. Care coordination between the hospital and
HHC is frequently inadequate and may contribute to med-
ication errors and readmissions. Insights from HHC
nurses could inform improvements to care coordination.
OBJECTIVE: To describe HHC nurse perspectives about
challenges and solutions to coordinating care for recently
discharged patients.
DESIGN/PARTICIPANTS: We conducted a descriptive
qualitative study with six focus groups of HHC nurses
and staff (n = 56) recruited from six agencies in Colorado.
Focus groups were recorded, transcribed, and analyzed
using a mixed deductive/inductive approach to theme
analysis with a team-based iterative method.
KEY RESULTS: HHC nurses described challenges and
solutions within domains of Accountability, Communica-
tion, Assessing Needs & Goals, and Medication Manage-
ment. One additional domain of Safety, for both patients
and HHC nurses, emerged from the analysis. Within each
domain, solutions for improving care coordination includ-
ed the following: 1) Accountability—hospital physicians
willing to manage HHC orders until primary care follow-
up, potential legislation allowing physician assistants and
nurse practitioners to write HHC orders; 2)
Communication—enhanced access to hospital records
and direct telephone lines for HHC; 3) Assessing Needs &
Goals—liaisons from HHC agencies meeting with patients
in hospital; 4) Medication Management—HHC coordinat-
ing directly with clinician or pharmacist to resolve dis-
crepancies; and 5) Safety—HHC nurses contributing
non-reimbursable services for patients, and ensuring that
cognitive and behavioral health information is shared
with HHC.

CONCLUSIONS: In an era of shared accountability for
patient outcomes across settings, solutions for improving
care coordination with HHC are needed. Efforts to im-
prove care coordination with HHC should focus on clearly
defining accountability for orders, enhanced communica-
tion, improved alignment of expectations for HHC be-
tween clinicians and patients, a focus on reducing medi-
cation discrepancies, and prioritizing safety for both pa-
tients and HHC nurses.

KEY WORDS: care transitions; care coordination; home health care;
hospitalist; primary care provider.
J Gen Intern Med 32(10):

1114

–21

DOI: 10.1007/s11606-017-4104-0

INTRODUCTION

Over the past several years, home health care (HHC) referrals at
hospital discharge have increased,1 which could be related to the
emergence of readmissions penalties,2 alternative payment
models that increase hospital accountability beyond discharge,3

and the growing number of older adults who need skilled HHC
services after discharge.4 A majority of older patients referred for
HHC at hospital discharge have Medicare insurance, which
requires that patients meet the following three conditions for
skilled HHC services to be reimbursable: 1) are under the care
of a physician, 2) have a need for a skilled HHC service (e.g.,
nursing, physical therapy) certified by a physician, and 3) are
homebound (e.g., have great difficulty leaving home due to a
medical condition).5, 6

Patients referred for HHC may be particularly vulnerable after
hospital discharge, as they are nearly 3 years older, have one
additional comorbidity, and have higher severity of illness than
patients discharged home without HHC.5 Readmission rates for
HHC patients are higher than the national average for high-risk
conditions such as heart failure (HF), in which 30-day readmis-
sion rates for Medicare beneficiaries discharged with HHC are as
high as 23–26%,7, 8 compared to a 21.9% overall national
average for Medicare patients discharged with HF.9

Electronic supplementary material The online version of this article
(doi:10.1007/s11606-017-4104-0) contains supplementary material,
which is available to authorized users.

Received February 2, 2017
Revised May 25, 2017
Accepted June 5, 2017
Published online July 13, 2017

1114

http://dx.doi.org/10.1007/s11606-017-4104-0

http://crossmark.crossref.org/dialog/?doi=10.1007/s11606-017-4104-0&domain=pdf

The high-risk characteristics of patients referred for HHC after
hospital discharge and suboptimal communication between HHC
and other clinicians may both contribute to readmissions from
HHC. In a study of HHC nurses in Norway, participants identi-
fied insufficient information exchange and communication with
clinicians in other settings as contributors to medication errors.10

In addition, communication failures between HHC nurses and
physicians have been found to increase the probability of hospital
readmission by nearly 10% in high-risk patients with HF who
receive HHC at discharge.11

As a partner in the continuum of care, nurses provide a
majority of HHC services and have a critical role in crafting
and implementing a patient’s plan of care after discharge.12, 13 An
evaluation of Medicare home health practices found that nurses
completed over 98% of the first HHC visits for Medicare pa-
tients.14 During the initial HHC visit, HHC nurses focus on
assessing a patient’s functional status, symptoms, medications,
and several additional aspects of care to complete the standard
Outcome and Assessment Information Set, in addition to
implementing physician orders for the start of care.15 The HHC
nurse scope of practice includes standards related to coordination
of care and communication, as well as collaboration with patients
and other clinicians.16 Yet, despite the key role of HHC nurses in
care transitions, little is known about nurse experiences in coor-
dinating care with other clinicians.
In a prior qualitative study, we found that both hospitalists

and primary care providers (PCPs) expressed reservations
about managing HHC orders following discharge.17 In that
study, hospitalists expressed the belief that once a patient was
discharged, HHC was the PCP’s responsibility, yet PCPs
described challenges in addressing HHC requests if they had
not yet evaluated a patient after discharge. As a result, HHC
clinicians may not receive orders or information needed to
provide optimal transitional care for patients.18 Because HHC
nurse insights could inform how to improve care coordination
to avoid readmissions from HHC, we sought HHC nurse
perspectives about challenges and solutions to coordinating
care for recently discharged patients.

METHODS

Study Design

We conducted a descriptive qualitative study of HHC nurses
and administrators recruited from HHC agencies in Colorado.
Six focus groups were conducted from September 2015
through June 2016, and were moderated by one of two team
members: a licensed social worker with health care experience
(DL) and a nurse with HHC experience (AR). Informed con-
sent and a written survey including questions about demo-
graphics, years in practice, agency characteristics (e.g., access
to hospital EHR), and receipt of information from hospital
(e.g., main contact for information) were completed by partic-
ipants at the beginning of each session. Group discussions
lasted an average of 59.5 min (range 56–61 min), and were

digitally recorded and transcribed verbatim. This protocol was
found to be exempt by the Colorado Multiple Institutional
Review Board (15–1281).

Population

We used a purposeful sampling strategy to recruit HHC agencies
who had an active referral relationship with our hospital and
diverse characteristics (e.g., for profit vs. not for profit). We
conducted focus groups within individual agencies because
nurses who deliver care in the same agency likely have common
experiences. We chose to focus on HHC nurses because they
complete a vast majority of the initial HHC visits with patients,
and therefore would have insights into coordinating care in the
time immediately following hospital discharge.14

Leadership from seven home health agencies was initially
approached by phone or email to determine interest in partic-
ipation. Six agreed to participate, and one for-profit agency
with a regional presence in Colorado did not respond. Within
interested agencies, email invitations were sent by agency
leadership to encourage nurses to participate in focus groups.
We requested that leadership recruit 6–10 participants, with a
maximum of 12 participants per group. This recruitment strat-
egy did not allow systematic collection of information about
those who did not participate in focus groups.

Framework

Domains selected from the Agency for Healthcare Research and
Quality (AHRQ) Care Coordination Measurement Framework
were mapped to interview guide questions (Online Appendix).19

This AHRQ framework was developed from a comprehensive
review of care coordination measures from multiple perspectives,
including patients, caregivers, and clinicians. We chose this
framework due to its broad applicability to care coordination
between individuals in different roles and settings. Domains were
selected based on relevance for care transitions from the hospital
to HHC, and were drawn from domains identified in prior
research with hospitalists and PCPs.17 The AHRQ framework
domains and definitions are as follows:

1) Accountability: defining responsibility of clinicians for
an aspect of a patient’s care

2) Communication: sharing knowledge among clinicians
participating in a patient’s care

3) Assessing Needs & Goals: determining care needs and
goals with input from the patient and clinicians caring
for the patient

4) Medication Management: reconciling medication lists to
avoid discrepancies and adverse events19

Analysis

The analysis team (CDJ, JJ, AR, DL) used an inductive theme
approach to identify commonly encountered challenges and

1115Jones et al.: Home Health Nurse Perspectives on Care CoordinationJGIM

solutions in care coordination, and deductively mapped these to
the AHRQ framework domains.20 Two team members coded
each transcript and resolved discrepancies through group discus-
sion. Using a team-based iterative approach,21, 22 the analysis
team met after every 1–2 focus groups to ensure that content was
building iteratively until we reached thematic saturation.23 Key
discussion themes and preliminary results were shared with focus
group representatives to perform member checks and re-
contextualize the analysis team’s interpretations. Analysis was
facilitated by ATLAS.ti, version 7.5.15 (Scientific Software De-
velopment GmbH, Berlin, Germany).

RESULTS

A total of 56 HHC nurses and administrators participated in
six focus groups. Demographic and agency-level data are
shown in Table 1. Most participants were women (93%), and
76% identified as HHC nurses. The 13 administrators held the
following positions: four directors or branch managers, three
nurse clinical managers, three home care coordinators, two
clinical service directors, and one managed referrals and clin-
ical oversight. Among HHC agencies, the number of full-time
employees (e.g., nurses; physical, occupational, or speech
therapists) ranged from 22 to over 100. Five of six HHC
agencies were for-profit. Four were freestanding and two were
part of a national chain. All were in the Denver metropolitan
area, and all used EHRs in their practices to provide clinical
care. Two agencies had access to the EHR of at least one
referring hospital.
Participants discussed multiple themes which mapped to the

framework domains of Accountability, Communication,
Assessing Needs & Goals, and Medication Management. An
additional domain of Safety in the home environment was
identified during analysis. The relationship among the five
domains is depicted in Figure 1. Themes within the Account-
ability and Communication domains were commonly in the
context of HHC nurse-initiated interactions with hospital cli-
nicians and PCPs. Both Accountability and

Communication

domains are included in the left-most circle to portray the lack
of clarity about responsibility for these domains between
hospital clinicians on the top and PCPs on the bottom. Themes
within Assessing Needs & Goals were frequently in the con-
text of attempts to coordinate care among the hospital clini-
cian, PCP, and HHC nurses, hence its location in the middle of
the figure. Themes within the Medication Management and
Safety domains were commonly described as something that
the HHC nurse navigates with the patient in the home. Results
are organized by the five domains, with related themes pre-
sented as challenges and solutions (Table 2).

Accountability

The importance of physician accountability for HHC orders,
and accountability related to payer requirements for physicians
to write HHC orders, were key themes. Resistance from the

hospital clinicians and staff to accountability for HHC is a
frequently encountered challenge, as in the following quote:

As a general rule, I’ve been told you’re not to contact
the hospitals. I actually got in trouble for contacting
the hospital, trying to find out, get more information,
trying to track a doctor down. I got in trouble for
involving the hospital people… my experience is they
don’t want us calling and trying to get more informa-
tion from the hospital.

Participants described challenges related to caring for pa-
tients caught between hospital clinicians and staff resistant to
taking responsibility after discharge, and a PCP lacking nec-
essary information to assume responsibility for HHC orders:

Call a [PCP] on the weekend and they say ‘I know
nothing…I didn’t know they were in the hospital. I don’t
have a report on this patient’ even though it’s their
patient… The communication between the hospital and
the [PCPs] is just as bad as it is for us, because the
PCPs don’t have the information.

However, finding hospital physicians willing to sign and
manage HHC orders until a patient visits their PCP helps to
overcome this challenge:

I had this stroke patient that has not established primary
care yet and the primary care …said they would not sign
or authorize home care to start until the patient came in
and initially had the first visit, so the neuro floor doctor
who saw the patient… actually agreed to follow home
care until the patient establishes…

Another key theme related to accountability is an
insurance requirement that only physicians can order
HHC services. As a result, when a nurse practitioner
(NP) provides primary care for a patient, obtaining HHC
orders can be challenging:

Table 1 Characteristics of Home Health Focus Group Participants
and Agencies

Home health focus group 54/56 participants in
6 focus groups completed
survey

Participant characteristics
Female 50 (93%)
Position

Home health nurse 41 (76%)
Administrator 13 (24%)

Years working in HHC 2.5 (1.2 SD)
Working at least 40 h/week at

agency
41 (77%)

Agency characteristics
Use EHR at practice 6 (100%)
Access to hospital EHR 2/6 (33%)
For-profit 5/6 (83%)
Freestanding 4/6 (66%)

1116 Jones et al.: Home Health Nurse Perspectives on Care Coordination JGIM

[We have] big problems too with using the primary
physician in some of the clinics… because most of the
patients… see nurse practitioners and not a doctor and
[insurance] requires us to have a physician’s order for
care.

One participant expressed support for anticipated legislation
allowing NPs and physician assistants (PAs) to sign HHC
orders to address this accountability challenge:

We’re trying to change it though from national level…
it’s on the legislative slate. It’s pretty much at the top.
And we support it. We would love … to be able to
accept [physician assistants’ and nurse practitioners’]
orders for home health. We’re for it.

Communication

The ability for HHC nurses to provide optimal care following
discharge often depends upon access to hospital records, and
the ability to reach clinicians involved in the patient’s care.
Lacking access to hospital records can lead to HHC encoun-
ters where important medical information is unknown,
resulting in unmet patient needs:

…it’s super common for us to send [a HHC nurse] out,
and they say ‘Oh, this patient has a wound. ‘ …we

Figure 1 Care coordination domains by clinician role and setting.

Table 2 Themes by Domain: Barriers and Facilitators

Domain Challenge Solution

1) Accountability Physician resistance to
accountability for HHC
orders

Hospital physician
willing to manage
HHC orders until
primary care follow-up

Insurance requirement
for physician to sign
HHC orders

Potential legislation
allowing physician
assistants and nurse
practitioners to sign
HHC orders

2)
Communication

Lacking access to
hospital records

Enhanced access to
hospital records (e.g.,
electronic health record
access)

Challenge connecting
with a physician by
telephone

Direct telephone access
to physician

3) Assessing
Needs & Goals

Poor understanding of
HHC services by
clinicians in hospital
and primary care

Liaisons from HHC
agencies meet patients
in hospital to align
clinician and patient
expectations

4) Medication
Management

Medication list
discrepancies

HHC coordinating
directly with clinician
or pharmacist to
resolve discrepancies

5) Safety Unclear safety for
patients with cognitive
difficulty at home

HHC nurses contribute
non-reimbursable ser-
vices for patients

HHC nurses feeling
unsafe in situations
with behavioral health

Ensuring cognitive and
behavioral health
information shared
with HHC

1117Jones et al.: Home Health Nurse Perspectives on Care CoordinationJGIM

didn’t know they had a wound…and so we have no
orders to put on a wound vac, but we have a wound vac
there and we have a wife screaming at us that we have
to put a wound vac on…

Enhanced access to a hospital’s EHR can improve HHC
through increased knowledge about emergency department
visits and hospitalizations. EHR access can also promote
proactive communications from the hospital:

…[the hospital case managers] will automatically
grant me access [to the hospital EHR]… so that we
can see what’s going on and we can print the ER visit if
the patient isn’t admitted…if the patient is being admit-
ted, they put a note in… [HHC agency name] is fol-
lowing, so then I get a call from the floor asking for a
report.

When participants encounter clinical questions, the chal-
lenge of connecting with a clinician, either from the hospital or
primary care clinic, is a critical challenge to providing optimal
HHC services. Although 63% (32 of 51) of participants indi-
cated on the survey that hospital case managers or social
workers were their main point of contact for information
following discharge, often HHC nurses need a physician’s
order or guidance. The frustration this creates for HHC nurses
is reflected in the following quote:

Getting a hold of a physician is kind of a fruitless
effort… we don’t get callbacks frequently…

On the other hand, a direct line to a clinician can facilitate
communication to avoid unnecessary hospitalizations, as in
this patient with cellulitis:

I actually got a hold of her PCP and she just extended
her [antibiotics]. [The PCP] just called in a new
prescription and avoided another probably unneces-
sary hospitalization…

Assessing Needs & Goals

Clinician understanding of HHC services is a key theme that
emerged within the domain of Assessing Needs & Goals. Poor
understanding of HHC services from both hospital clinicians
and PCPs was discussed in nearly all groups as a contributor to
unmet patient expectations with HHC.

One thing I’d say about the discharge process is the
hospital not explaining to the patient what to expect
from home health care…So it kind of sets an unfortu-
nate expectation for us … and so the expectation at that
time is shattered, you know, in the way [the patients
are] viewing us, so then [we] have to rebuild this
relationship.

However, liaisons from HHC agencies who meet with
patients in the hospital to explain and coordinate HHC services
can help to better align patient and HHC nurse expectations:

Optimally, as the liaison if you get the call before the
hospital discharges the patients, you can come out,
meet with the patient, get the records, get the orders…
and let the patient know what the expectations are, this
is who is going to see you, this is what your orders are
for …and then the [HHC nurse] has that information
on her device as she goes out to see the patient…

Medication Management

In most groups, participants described medication list discrep-
ancies resulting from suboptimal communication and unclear
accountability between clinicians in the hospital and clinic
settings:

…most medication lists are incorrect because there’s
multiple doctors involved… The list that you have
doesn’t match what the patient has at home. The list
that the primary doctor has doesn’t match the list that
was in the hospital so, you know, it becomes a real sort
of a knot that we have to untangle…

This lack of communication between medication pre-
scribers in different settings can contribute to medication
errors:

…it’s even more scary when they have a cardiologist
and then a kidney specialist, and they’re all prescribing
different meds… [the patient will] have atenolol and
metoprolol… all these different kind of medications for
the same thing by different doctors, and [the doctors]
don’t know that the patient has that from another
doctor so…it’s really scary.

However, coordinating directly with a PCP office or phar-
macist can help resolve medication discrepancies:

[With the primary care office]…over the phone, we just
went over every single medication and what the dosage
was, how often [the patient was] supposed to take it
and … it was so helpful ‘cause now [the patient] has an
accurate med list in the home, she knows what she’s
taking …

Safety

Safety in the home environment for patients and HHC
nurses was a new domain that emerged during analysis.
The patient experience of safety in their home is best
understood by HHC nurses, but not always fully under-
stood or communicated by hospital clinicians, particular-
ly in the case of cognitive impairment:

1118 Jones et al.: Home Health Nurse Perspectives on Care Coordination JGIM

I mean, we see many at home that maybe are living
alone and there is some element of dementia …they
may not have a lot of dementia on board, but always
that transition … out of a facility back home again,
there is a period of confusion. You see it all the time,
you know, trying to transition, and it usually takes
about a week and then they’re back into their
environments…

Yet, patients often have a strong desire to stay at home, even
in the context of ailing health:

[The patients] would rather struggle with what they
have than to be removed (from home).

The HHC nurse experience of safety within a patient’s
home was another part of this emergent theme, and was
described in the context of caring for patients with behavioral
health conditions:

Participant 1: I’m reading the H&P, and it says, you
know, he’s got homicidal tendencies and I’m thinking…
Participant 2: Does he have a gun?
Participant 1: …did anybody read this? I mean, what’s
going on here? … and you want me to go there…By
myself.

To improve patient safety and health at home, participants
described going above and beyond for patients to contribute
support beyond clinical care:

We’re there for them. We’re interested in them, and I
can’t tell you how many thousands of dollars I’ve prob-
ably spent on groceries and medical supplies…that’s a
big bugaboo, and that happens across the board…

For facilitating HHC nurse safety, participants emphasized
the importance of including key history elements such as
cognitive impairment, behavioral health, and psychiatric diag-
noses in discharge information available to HHC agencies.
Increased information about patient conditions was noted as a
key item both for the delivery of appropriate services and for
ensuring safety for HHC nurses, who are often alone while
visiting patients in their homes.

DISCUSSION

HHC nurses described a range of challenges and solutions to
coordinating care for recently discharged patients within the
domains of Accountability, Communication, Assessing Needs
& Goals, Medication Management, and Safety. Although the
focus of group discussions often gravitated to challenges,
multiple best practices and aspirations were identified to guide
future improvement efforts, as shown in Table 2.

In our study, medication discrepancies were described as a
frequent problem in HHC. This aligns with prior studies, in
which 94% to 100% of patients had at least one medication
discrepancy when HHC and referring provider medication
lists were compared.24, 25 Because adverse events for patients
after hospital discharge are most commonly medication-relat-
ed,26 the high rate of medication discrepancies in HHC may
contribute to adverse outcomes for patients. In a Norwegian
study exploring HHC nurse perspectives about medication
errors in home care, participants identified suboptimal infor-
mation exchange and communication between clinicians as a
contributor to medication errors.10 In another recent study,
researchers found that the presence of communication failures
between HHC and physicians was associated with a nearly
10% increase in the probability of hospital readmission among
high-risk HHC patients with HF.11 Our study illustrates that
unclear accountability and inadequate communication likely
contribute to medication errors and suboptimal safety for both
HHC nurses and patients, which may in turn contribute to
adverse patient outcomes such as readmissions.
Solutions discussed by participants could inform multiple

quality improvement initiatives to improve care coordination
for patients discharged with HHC, as outlined in Table 2. For
example, clearly establishing accountability for hospital clini-
cians in managing HHC orders until PCP follow-up could
provide clarity for HHC nurses about whom to contact with
questions. Such a solution would address concerns identified
by PCPs in our prior qualitative study, who noted challenges in
addressing questions from HHC when they had not yet eval-
uated the patient; PCPs in that study also suggested having
hospitalists accountable for HHC for a set amount of time after
discharge.17 However, extending hospitalist responsibility for
HHC questions would likely require additional social and case
management support within the hospital to coordinate and
triage HHC requests.
In addition, hospitals and PCPs could improve communi-

cation by providing HHC agencies with access to EHRs and
direct phone lines. Participants from HHC agencies with read-
only access to hospital-based EHRs noted multiple advantages
to having this access, including having patient appointment
dates and medication lists. Of note, hospitalists and PCPs in
our prior study also sought access to direct phone lines and
EHRs for clinicians in other clinical settings in order to im-
prove care coordination.17

An example of a policy-level solution that could improve
accountability for HHC orders would be giving PAs and NPs
the authority to write HHC orders, as proposed in a bill that
was recently brought before Congress but was not passed into
law (H.R. 1342/S. 3435).27 Broadening HHC order capabili-
ties to PAs and NPs would help facilitate HHC following
discharge, particularly in primary care clinics in which an
NP may be a patient’s PCP and the clinic may not have a
physician, as noted by participants.
In addition to solutions identified in this study, it is impor-

tant to consider how innovative models of transitional care

1119Jones et al.: Home Health Nurse Perspectives on Care CoordinationJGIM

could be partnered with HHC to address difficulties in care
coordination. For example, the Geriatric Resources for As-
sessment and Care of Elders (GRACE) model includes an NP
and social worker assessment in the home for low-income
older adults who are eligible for both Medicare and Medic-
aid.28 The NP and social worker take responsibility for coor-
dinating care for the patient among hospital clinicians, PCPs,
HHC clinicians, caregivers, and others during and after hos-
pitalization. This model reduced hospitalization and total
health care costs for GRACE participants compared to con-
trols, and could be a promising approach for improving tran-
sitional care for other high-risk populations.
Although our focus groups were limited to HHC agencies in

the Denver metropolitan area, participants were comparable to
workforce estimates of HHC—93% of participants were fe-
male, which is comparable to the 89% of the HHC service
industry that is female.29 In addition, 83% of HHC agencies in
this study were for-profit, which is comparable to the 80% of
for-profit HHC agencies nationally.30 Limitations to this work
include unknown demographics or perspectives from nurses
who may have been invited but opted not to participate in
focus groups. Because we limited our study to HHC nurses,
we do not have perspectives from other clinicians (e.g., phys-
ical therapists) in HHC, which could provide additional con-
text. Our results may not be generalizable beyond the context
of study participants.
As the US health system promotes shared accountability for

patient outcomes across settings, the need to address fragmen-
tation in care coordination is increasingly important. Our
findings in this study suggest that improvements to account-
ability and communication could address patient needs and
goals, avoid medication discrepancies, and ultimately improve
safety for patients and HHC nurses. Clinician-led efforts to
improve care coordination with HHC should focus on clearly
defining physician accountability for HHC orders, improving
communication by providing EHR access and direct phone
lines for HHC, improving alignment of expectations for HHC
between clinicians and patients, coordinating with HHC to
reduce medication discrepancies, and prioritizing safety for
both patients and HHC nurses by ensuring that cognitive and
behavioral health information is provided to HHC clinicians.
Future work to better understand HHC patient and caregiver
perceptions of care coordination, as well as care needs beyond
reimbursable HHC services such as transportation, meal ser-
vices, and additional caregiving support, could inform efforts
to refine reimbursement and inform innovation to support
patients’ desires to remain in their homes.31

Corresponding Author: Christine D. Jones, MD, MS; University of
Colorado Denver School of Medicine, Hospital Medicine Division,
Aurora, CO, USA (e-mail: christine.jones@ucdenver.edu).

Contributors The authors would like to acknowledge the valuable
contributions of all study participants. The authors also wish to thank
Sue Felton for her contributions.

Compliance with Ethical Standards:

Funders: Dr. Christine D. Jones is supported by grant number
K08HS024569 from the Agency for Healthcare Research and Quality
for this work. The content is solely the responsibility of the authors and
does not necessarily represent the official views of the Agency for
Healthcare Research and Quality. This work was supported by a grant
from the University of Colorado, School of Medicine, Department of
Medicine, Division of General Internal Medicine.

Prior Presentations: This work was presented at the Society of Hos-
pital Medicine meeting in San Diego, California on March 7, 2016 and
at the American Geriatrics Society meeting in Long Beach, California,
on May 19, 2016.

Conflict of Interest: The authors declare that they do not have a
conflict of interest.

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JGIM: Journal of General Internal Medicine is a copyright of Springer, 2017. All Rights
Reserved.

“Connecting…

Abstract
Abstract
Abstract
Abstract
Abstract
Abstract
INTRODUCTION
METHODS
Study Design
Population
Framework
Analysis
RESULTS
Accountability
Communication
Assessing Needs & Goals
Medication Management
Safety
DISCUSSION
References