Older Adults’ Experience of Person- and Family-Centered Care During the Discharge Planning Phase From Hospital to Home

The Ontario Health Team (OHT) is a partnership of healthcare organizations that provides services to residents across Ontario, Canada. With an aging population and increasing care complexities, the OHT identified challenges in transitions from hospital to home for older adults. To better understand these experiences, the OHT steering committee partnered with the Registered Nurses' Association of Ontario (RNAO) to conduct a quality assessment study focused on person- and family-centred care during discharge planning. Using a holistic descriptive case study approach, the project team followed three older adult participants through observation and in-depth interviews to examine how interactions between clinicians, patients, and families reflected core principles of person- and family-centred care. Findings highlighted the vulnerability associated with hospital-to-home transitions and emphasized the need for enhanced support and resources during this period. Although participants generally reported satisfaction with their care and positive therapeutic relationships, several improvement opportunities were identified. Key recommendations include providing targeted education on effective communication with older adults, adopting standardized communication tools, and prioritizing home safety assessments before discharge to ensure appropriate equipment selection and fit. These strategies can strengthen transition processes and improve experiences for older adults within the OHT.