In 2012, nearly one-third of older adults (>65 years) with Medicare discharged to home after hospitalization were referred for home health care (HHC) services. Care coordination between healthcare settings is frequently inadequate. We sought to describe care coordination challenges and potential solutions from the perspective of HHC nurses.


We conducted a qualitative descriptive study with 5 focus groups of 47 HHC nurses recruited from 5 HHC agencies in Colorado. Interview guides were based on themes from the AHRQ Care Coordination Measurement Framework. Focus groups were recorded, transcribed verbatim, and analyzed using a general inductive approach to theme analysis using ATLAS.ti software. Two team members independently coded transcripts and resolved discrepancies through group discussion.


HHC nurses encounter many challenges to care coordination, including:  1) hospital and outpatient physician resistance to accountability for HHC orders, 2) lack of access to hospital records, 3) difficulty reaching hospital and outpatient physicians, 4) payer constraints that HHC orders must come from MDs or Dos (rather than NPs, PAs), and 5) clinician misconceptions about HHC services leading to discrepancies between patient expectation HHC capabilities.

Facilitators of care coordination with HHC nurses include:  1) a hospital physician willing to sign HHC orders until outpatient follow up, 2) access to records from the hospitalization, 3) a designated individual in the hospital or clinic to promote timely responses to HHC inquiries, 4) liaisons from HHC agencies being permitted in the hospital to explain and coordinate HHC services with patients.


Solutions to improve care coordination with HHC clinicians are needed, and should include: 1) clearly defined clinician accountability for HHC orders prior to discharge, 2) HHC access to hospital records, 3) a designated individual in hospital and outpatient settings who is accessible to HHC nurses, 4) ability for NPs and PAs to order HHC, and 5) ordering clinician and patient education about HHC to promote alignment between patient expectations and HHC capabilities.