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Nurses Coordinating Care for Discharged Patients


The article under analysis is entitled “Connecting the Dots: A Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently Discharged Patients” and was published in 2017. Jones et al. (2017) conducted a qualitative study that involved focus group discussions. Home health nurses and administrators shared their views on the major challenges and opportunities of the provision of high-quality care to patients who had been discharged.

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Research Problem, Purpose, and Research Question

The hospital readmission is one of the most urgent issues to be addressed since it contributes to the increase in healthcare services costs. The admission rate of older home health care (HHC) beneficiaries of Medicare is rather high and reaches up to 26% (Jones et al., 2017). One of the factors contributing to the number of readmissions is the poor quality of HHC services provided to the elderly discharged from hospitals. In its turn, HHC services tend to depend on the collaboration of home health nurses and hospital healthcare professionals. The purpose of this research is to identify the barriers to the effective provision of home healthcare services as seen by home health nursing practitioners. The researchers do not outline their exact hypotheses or research questions, but they are rather obvious as Jones et al. (2017) try to identify challenges and opportunities of HHC nurses’ practice.

Evaluation of the Findings

The findings are consistent with the framework since the researchers aim at examining the views of nurses, so the qualitative analysis is the most appropriate research design to be employed. Some of the major findings were the inconsistency of medication prescriptions and insufficient communication among hospitalists and home health nurses (Jones et al., 2017). The results were rather expected and consistent with the previous research. Jones et al. (2017) refer to numerous studies conducted on the matter. No serendipitous findings were highlighted in the article under analysis.

Limitations, Conclusions, Implications of the Study, and Recommendations

Jones et al. (2017) describe some limitations of their study. They note that the sample was rather small and homogenous. Over 90% of participants were females, and the researchers explored nurses’ views only. The research was also confined to a certain area so the applicability of findings to other areas can be questionable. Jones et al. (2017) note that the perspectives of other healthcare professionals (for example, physicians) may be needed. The researchers note that one of the possible implications may be the use of the study results as the basis for a new paradigm for home health nursing practice and the further research on this matter. The conclusions and implications reported are informed by the findings of the study. Jones et al. (2017) note that a more effective communication pattern is necessary. However, the findings can equip researchers with the framework for a new study aimed at the evaluation of interventions that imply close communication among hospital and home health nurses.

My Practice

This research provides helpful insights into the way HHC nurses see their practice. This information can be instrumental in the development of the intervention that implies the collection of additional information from hospitalists. It is obvious that nurses see the lack of communication and medication prescription inconsistencies as serious challenges associated with the high rate of readmissions. The call for the development of an information system that could be accessed by hospital and HHC healthcare professionals is also evident.


Jones, C. D., Jones, J., Richard, A., Bowles, K., Lahoff, D., Boxer, R. S., … Wald, H. (2017). “Connecting the dots”: A qualitative study of home health nurse perspectives on coordinating care for recently discharged patients. Journal of General Internal Medicine, 32(10), 1114-1121.

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