Provider Perspectives, Barriers, and Improvement Strategies for Hospital Discharge Support Programs: A Focus Group Interview Study in Korea
Article information
Abstract
Objectives:
Transitional periods, such as patient discharge, are notably challenging. This study aimed to explore the perceptions of providers involved in hospital discharge support programs, identify the primary obstacles, and propose strategies for improvement.
Methods:
In this qualitative cross-sectional study, we interviewed 49 healthcare professionals, comprising doctors, nurses, and social workers, who participated in two pilot programs. We organized focus group interviews with 3-6 participants per group, segmented by the type of discharge support program and profession. For data analysis, we employed phenomenological analysis, a qualitative method.
Results:
Participants recognized the importance of the discharge support program and anticipated its benefits. The Rehabilitation Hospital Discharge Patient Support program saw more active involvement from doctors than the Establishment of a Public Health-Medical Collaboration System program. Both programs highlighted the critical need for more staff and better compensation, as identified by the doctors. Nurses and social workers cited the heavy documentation burden, uncooperative attitudes from patients and local governments, and other issues. They also anticipated that program improvements could be achieved through the standardization of regional welfare services and better coordination by local governments serving as welfare service regulators. All groups—doctors, nurses, and social workers—underscored the significance of promoting these programs.
Conclusions:
Discharge support programs are crucial for patients with functional impairments and severe illnesses, particularly in ensuring continuity of care. Policy support is essential for the successful implementation of these programs in Korea.
INTRODUCTION
After hospitalization, patients can be admitted to long-term care facilities, experience a decline in daily living functions, and even die [1,2]. Transitional periods such as discharge pose significant challenges for patients due to numerous changes in medication, treatment, and medical staff [3]. The absence of proper coordination during this time can lead to preventable readmissions, complications, and increased healthcare costs, worsening daily living and treatment outcomes [4,5]. Transitional care, including discharge planning, is essential for patients with complex needs to ensure a successful return home [6,7]. In this context, various pilot studies on transitional care have been launched in several countries [4,8-10]. Unlike other countries where primary care physicians commonly coordinate integrated healthcare management, primary care in Korea is not well established. In Korea, there is no primary care physician system, and coordination between medical institutions is typically conducted solely through referral letters without direct communication between the institutions. This results in poor connections between individual medical institutions. Therefore, the Korean government has initiated pilot programs focused on transitional care during hospital discharge to fill this gap.
Current pilot programs include the establishment of a Public Health-Medical Collaboration System for patients discharged from acute care, an Acute Care Patient Discharge Support and Community Linkage program, and a Rehabilitation Hospital Discharge Patient Support program. The Public Health-Medical Collaboration System and the Acute Care Patient Discharge Support and Community Linkage programs are primarily implemented in tertiary and general hospitals [11]. The Public Health-Medical Collaboration System is a project where designated medical institutions strengthen linkage and collaboration among essential public health services within their respective regions to avoid gaps in critical healthcare. This initiative encompasses a wide range of areas, from establishing networks for collaboration between local medical institutions to covering pre-hospital, in-hospital, and community reintegration processes. The discharge support program is one of the key components of this project [11]. The Public Health-Medical Collaboration System ensures seamless health management of patients even after discharge. This includes an in-depth assessment of inpatient conditions, the establishment of care plans, and the integration of medical and welfare services along with health monitoring in the community post-discharge. The program targets diseases such as stroke, heart disease, respiratory diseases, fractures, cancer, rehabilitation needs, and chronic diseases. Each participating institution can select specific diseases to focus on as part of this program. The Rehabilitation Hospital Discharge Patient Support program aims to improve the effectiveness of rehabilitation treatment by managing residual disabilities of patients with mobility impairments through home-based rehabilitation after discharge from rehabilitation hospitals. This program targets patients who have received intensive treatment for acute conditions, such as stroke or spinal cord injuries, and are assessed as needing home-based rehabilitation post-discharge. A multidisciplinary team evaluates these patients to facilitate home-based rehabilitation and integration with community resources [12]. Although these 2 programs were initiated based on different social concerns, they have both implemented the most feasible policy—namely, the discharge support program—as part of the policy agenda of providing comprehensive and continuous services to patients after discharge (Table 1). In all these programs, multidisciplinary teams comprising doctors, nurses, and social workers collaborate to develop discharge plans and facilitate coordination. Despite these efforts, transitional care in Korea still faces significant challenges.
Policy framework for discharge support programs
Although research has been conducted on discharge support programs [13], no studies have comprehensively captured the perspectives of all participating professions, often focusing solely on operational issues. Thus, there has been limited discussion regarding the overall perceptions, problems, and potential improvement strategies for these programs. To bridge this gap, we opted for qualitative research methods instead of surveys to initially understand the thoughts of the program participants.
This study aimed to explore the major issues and propose improvement strategies for discharge support programs within the context of transitional care at hospital discharge. We gathered feedback on these issues and potential improvements by interviewing program participants.
METHODS
We conducted focus group interviews (FGIs) to assess the perceptions of current members involved in the discharge support program, as well as to identify major issues and potential improvements. FGIs help capture respondents’ thoughts, which can be challenging in quantitative research, and identifies commonalities through group discussions [14,15]. This study utilized FGIs to collect shared opinions from members across various institutions and to elicit diverse perspectives on problems faced by the program and strategies for improvement. This study was conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) [16].
Study Design and Participants
This qualitative cross-sectional study involved interviews with 49 healthcare professionals, including doctors, nurses, and social workers, who participated in two pilot programs: the Establishment of a Public Health-Medical Collaboration System and the Rehabilitation Hospital Discharge Patient Support program. The Acute Care Patient Discharge Support and Community Linkage program was excluded due to its overlap with the public health-medical collaboration system in terms of participating institutions and target patients.
We identified the medical institutions participating in the discharge support program using claim data from the National Health Insurance Service (NHIS) and the National Medical Center (NMC). The managers of the discharge support program at these institutions were identified through the institutions’ websites and the NMC, which oversees the program. We then sent emails to these managers, providing information about the study and requesting their cooperation. Following the emails, our internal research team contacted each manager by phone to further explain the study and request their cooperation.
The doctors, nurses, and social workers selected for interviews at each medical institution were recommended by the program managers.
Interview Methods
The guideline development process for conducting FGIs is as follows: Initially, we aimed to identify the key information we needed to gather from the survey. To achieve this, we reviewed the guidebooks for each discharge support project and conducted face-to-face interviews with the project managers. We carried out a preliminary survey focusing on the content, challenges, and future direction of the project as envisioned by the project manager. Subsequently, we crafted the primary questions to be explored through the FGI. These questions were developed by our internal researchers and were finalized after consulting with external experts.
Each FGI was conducted in 4 distinct stages: the warm-up stage, the bridge stage, the main stage, and the ending stage. During the warm-up stage, participants introduced themselves. In the bridge stage, they shared their opinions on the necessity of the discharge support project. The main stage involved discussing key questions, and the ending stage concluded with a summary of the discussions and provided an opportunity for further explanation.
We divided FGI participants into groups of 3-6 people based on their involvement in specific discharge support programs and their professional roles. In the Public Health and Medical Cooperation System Construction Project, we interviewed a total of 25 participants, divided into two groups of doctors (6 participants), one group of nurses (11 participants), and one group of social workers (8 participants). For the Rehabilitation Medical Institution Fee Pilot Project, we interviewed a total of 24 participants, comprising two groups of doctors (9 participants), one group of nurses (2 participants), and one group of social workers (13 participants) (Figure 1). Trained interviewers, under the supervision of researchers, conducted these sessions.
Research framework diagram.
A tailored FGI questionnaire was administered to doctors, nurses, and social workers. For doctors, who often had limited knowledge of specific pilot programs, the questions addressed the necessity of discharge support programs, criteria for determining the need for support post-discharge, doctors’ roles, required post-discharge services, main issues with and improvement ideas for the program, and suggestions for increasing doctor participation. For nurses and social workers, who typically managed the programs, questions focused on the programs’ necessity, collaboration with doctors, key issues and suggestions for improvement within each program, problems related to community services and service coordination after discharge, and examples of successful and unsuccessful local coordination.
The survey was conducted from August 10, 2023 to August 29, 2023, using video conferencing as the method of interviewing. The same interviewer and researcher consistently applied the same methodology across all groups. Prior consent was obtained from the participants before videotaping the survey process. The interviews followed semi-structured guidelines and averaged 2 hours in duration (Supplemental Material 1).
The researcher who participated in the interview was a man with a doctorate in public health. The interviewer, a woman, held a degree in policy studies and had prior experience in conducting qualitative research, including focus group interviews and individual interviews. Neither the interviewer nor the researcher had any prior relationship with the study participants. The comprehensive transcript provided by the research company was summarized and organized by the internal researchers of this study to highlight key information.
Statistical Analysis
Data were analyzed using phenomenological analysis, which is a qualitative method. This approach aims to describe and interpret experiences to comprehend their underlying meanings. In phenomenological analysis, researchers identify key themes and subthemes and explore recurring themes across interviews to reveal the essence of the experiences [17]. We employed Van Kaam’s method, which typically involves repeatedly listening to and transcribing interview content verbatim. However, to minimize repetition, we used an automatic recording application [18]. Subsequently, meaningful statements were extracted from the recorded content, and a categorization process was conducted by grouping statements with common attributes into subthemes. These subthemes were then organized into broader themes, which were grouped into categories. To ensure objectivity, the co-authors independently analyzed the data. In instances where analysis results differed, discussions were held until a consensus was reached through repeated analysis cycles.
Ethics Statement
Individuals who were informed about the study and agreed to participate were enrolled. The study was ethically approved by the Institutional Review Board of the NHIS, with the approval number 2023-HR-04-002.
RESULTS
General Characteristics of Participants
The study included 17 male (34.7%) and 32 female (65.3%) participants. The largest age group was 30-39 years, which accounted for 38.8% of the participants. Regarding hospital affiliation, 15 participants (30.6%) were from tertiary hospitals, 10 (20.4%) from general hospitals, and 24 (49.0%) from rehabilitation hospitals. Twenty-five participants were involved in the Establishment of a Public Health-Medical Collaboration System program, and 24 participants were involved in the Rehabilitation Hospital Discharge Patient Support program. In the Establishment of a Public Health-Medical Collaboration System program, the work experience of doctors and nurses ranged from 3 years to 34 years, indicating generally high levels of experience, while social workers had more variability, with a range from 1.8 years to 11.0 years. Similarly, in the Rehabilitation Hospital Discharge Patient Support program, doctors and nurses had work experience ranging from 5 years to 45 years, and social workers’ experience ranged from 1.4 years to 15 years. The work experience in both programs ranged from 0.5 years to 4.0 years, showing no significant difference (Table 2, Supplemental Material 2).
Characteristics of participants
Four themes emerged in the interviews: (1) perceptions of discharge support programs, (2) identifying patients and areas in need of discharge support, (3) obstacles to discharge support programs, and (4) recommendations for enhancing discharge support programs. A total of 11 sub-themes were identified for each program (Table 3).
Themes extracted from the interviews
Perceptions of the Discharge Support Programs
Establishment of a Public Health-Medical Collaboration System program
Participants in the Establishment of a Public Health-Medical Collaboration System program unanimously agreed on the necessity of the discharge support program. Doctors, nurses, and social workers involved in the program indicated that the discharge support program is essential, as it alleviates the burden on caregivers and aids patients with limited caregiver support, enabling them to receive care at home rather than in hospitals.
“Elderly patients often need a lot of attention after their diseases are treated, but hospitals have almost no services for the elderly, so a linkage program is necessary.” (Doctor A)
“Even if there are welfare systems, it’s often hard to connect them, and many patients can’t find services that meet their needs, so we need to actively find them.” (Nurse A)
Regarding the efficacy of the program, doctors acknowledged that providing information and linking services could be beneficial; however, they expressed uncertainty about whether these measures were actually implemented. Nurses and social workers noted the program’s benefits but pointed out that due to patient reluctance, strict eligibility criteria for services, and changes in conditions from service providers, only 30-50% of the linkages were successful. This suggests that the program requires further improvement. Doctors typically played a crucial role in deciding on the final support for identified subjects and in managing consultative bodies. Nurses and social workers, whose roles varied by institution, were involved in the entire process, from identifying subjects to evaluation, planning, and linkage.
Rehabilitation Hospital Discharge Patient Support program
All participants in the Rehabilitation Hospital Discharge Patient Support program, including doctors, nurses, and social workers, concurred on the necessity of the program, emphasizing its role in facilitating patients’ return to the community.
“Even if simulated training is done in a hospital environment, it’s different from the real environment, so it’s very necessary to help with activities of daily living and health maintenance.” (Doctor B)
“I think the discharge support program is necessary, and through it, we can establish a discharge plan and help reduce patients’ and caregivers’ anxiety about returning to the community.” (Social Worker A)
Most participants recognized that linking essential services enhances patient satisfaction and provides benefits; however, when services such as home repairs are challenging to secure, the perceived effectiveness of the discharge support program diminishes.
“There was a high demand for structural modifications like home repairs, but it seemed difficult to provide those services.” (Doctor C)
Patients and Areas Needing Discharge Support
Establishment of a Public Health-Medical Collaboration System program
Doctors primarily indicated that patients requiring discharge support typically have specific diseases or conditions, including stroke, respiratory diseases, heart diseases, and frailty. Conversely, nurses and social workers suggested that discharge support is also necessary for patients who live alone or have families that struggle to provide care.
“Most stroke patients need discharge support because they are often discharged with residual symptoms.” (Doctor D)
“With the increase in single-person households, managing medication and performing rehabilitation and exercises at home becomes difficult after discharge. There’s also a lack of social welfare information and initial post-discharge management (within 1-2 weeks) for these patients. Even if they have family members, they are often unable to provide actual care due to work.” (Social Worker B)
Doctors ranked housekeeping support, housing support, and visiting nursing as their top priorities, in that order. Conversely, nurses and social workers prioritized housekeeping support, mobility support, and visiting nursing, highlighting differences in their priorities.
Rehabilitation Hospital Discharge Patient Support program
Doctors indicated that the program is necessary for patients who need training for themselves or their caregivers, as well as for those facing non-medical discharge challenges. Nurses and social workers have pointed out that the current selection criteria, including restrictions based on the length of inpatient stay, are unreasonable. They recommended broadening the target audience of the program.
“I thought the 30-day hospitalization criterion for conditions like hip fractures was too short. Especially when guiding patients for long-term care applications, those discharged within a month often get rejected, so the duration needs to be extended.” (Social Worker C)
Doctors identified home rehabilitation or house repair as the most necessary services, whereas nurses and social workers prioritized housekeeping support, indicating variations in perceived needs.
Barriers of the Discharge Support Programs
Establishment of a Public Health-Medical Collaboration System program
The main barriers identified for the program included a lack of resources and services, the burden of documentation and operational challenges, and low participation of doctors. Doctors suggested increasing resources such as manpower and budget, and creating incentive systems linked to hospital profits and doctors’ willingness to participate. Nurses and social workers noted that unclear and diverse welfare or health resources in the region complicate the planning process. They also highlighted that patients who do not meet certain income thresholds or are not already welfare beneficiaries often cannot access services. Challenges such as early patient discharge, frequent consultations within hospitals, and varying documentation requirements across administrative districts were also reported.
“Having nurses and social workers as full-time dedicated staff would be beneficial.” (Doctor E)
“If we institutionalize this with health insurance, hospitals will see profit increases, which would motivate hospital management to promote participation from doctors by offering incentives.” (Doctor F)
“A lack of prior explanation to caregivers about discharge often leads to complaints when we contact them.” (Social Worker D)
“Nurses and social workers mostly establish the plans because doctors find it hard to participate during working hours, so doctors’ input is often limited to final suggestions.” (Nurse B)
Rehabilitation Hospital Discharge Patient Support program
Major barriers in this program included insufficient reimbursement, operational challenges, and lack of coordination. Doctors emphasized the need for adequate reimbursement to cover the time and person-hours required.
“The reimbursement is too low compared to the personnel and time required, so very few hospitals implement it properly.” (Doctor G)
“To promote on-site visits and management, financial incentives should be increased.” (Doctor H)
Operationally, doctors emphasized the need for objective selection criteria and guidelines. Nurses and social workers pointed out challenges in communicating with patients due to cognitive impairments, differing opinions between patients and caregivers, and patients’ reluctance to disclose sensitive information.
“It’s challenging when patients or caregivers feel uncomfortable with sensitive questions during evaluations.” (Social Worker E)
All groups agreed that the lack of coordination was a barrier, highlighting the absence of a central control tower for the program and the varying information requirements from municipalities and government agencies.
“Even though we know a lot, linking services across municipalities is difficult due to varying requirements and inconsistent information from different officials.” (Social Worker F)
Recommendations to Improve the Discharge Support Programs
Establishment of a Public Health-Medical Collaboration System program
Participants identified 3 key areas for improvement: team restructuring, enhancement of the reimbursement system, and process improvement. They advocated for an increase in nursing and social worker staff, as well as a reorganization of overlapping roles within hospital teams. Doctors highlighted the need for guaranteed hospital profits and incentives for participating physicians, whereas nurses and social workers focused on improvements in health insurance reimbursements. Additionally, they suggested the creation of a coordination function to integrate local resources via a unified portal.
Rehabilitation Hospital Discharge Patient Support program
Participants suggested standardizing services across regions, enhancing the reimbursement system, and improving processes. Nurses and social workers advocated for the standardization of welfare services across different regions, whereas doctors called for higher reimbursement fees. Proposed process improvements involved promoting the program via academic societies and medical associations, as well as coordinating fragmented local services with municipalities serving as facilitators (Table 4).
Interview results by profession
DISCUSSION
Our study results revealed unanimous agreement among all participants on the necessity of discharge support programs. However, a significant challenge identified was the lack of interest and participation from doctors, who are the final decision-makers. Addressing this issue is crucial for the successful activation of these programs, as doctors play a key role in formulating discharge plans essential for effective discharge management. Additionally, if doctors do not provide prior explanations or if patients are not well-informed about the programs, patients may exhibit uncooperative attitudes. This can lead to increased time investment and coordination failures. Therefore, it is essential to improve the preliminary explanations provided by the medical staff. From the patient’s perspective, explanations about discharge support may seem complex, necessitating clear and simple introductions to the program and efforts to build relationships [19]. Previous research suggests that increasing medical staff participation requires an understanding of the program’s necessity, along with incentives and motivation, and clear role assignments within the program [20]. Therefore, to enhance the program’s activation, improving doctors’ compensation and incentives to increase their participation will be necessary.
In our study, the participants identified as the target population for discharge support programs included individuals hospitalized for diseases that cause functional impairment, those with diminished functionality, and those in need of training or care. This indicates a need to broaden the current target population of discharge support programs to encompass patients with more complex needs. Previous research on transitional care programs has predominantly focused on specific patient groups, including those with heart failure, mental illness, stroke, hip fractures, as well as older adults and frail individuals with complex issues [21-23]. Meta-analyses involving these populations have shown associations with reduced readmission rates, fewer adverse reactions, and improved medication adherence, particularly when interventions incorporated medication reviews, post-discharge phone follow-ups, and other monitoring services [21]. The expert consensus also recognizes individuals with complex needs as the primary target for transitional care [24]. Therefore, it is necessary to expand the target population for transitional care to include those with complex needs and to continuously refine criteria such as income level and length of hospital stay to adapt to local contexts and enhance program effectiveness.
It is also important to develop comprehensive services tailored to the needs of the target population [9]. Service providers have consistently highlighted a shortage of resources and services. If the program continues to concentrate solely on evaluation without expanding these resources and services, delivering high-quality services that patients genuinely value will remain challenging. Previous studies have similarly reported this lack of resources and services [13,19,25]. There is a need to standardize local welfare services and broaden the range of options available to patients in discharge support programs.
Effective resource allocation is crucial for managing transitional care [26], and it is vital to establish collaborative relationships among patients, healthcare professionals, and local communities [27]. However, the reluctance of local governments to cooperate has been identified as a significant barrier. Numerous studies have highlighted substantial challenges in forming effective community linkages [13,24,28]. Participants in the discharge support program expect local governments to serve not only as cooperative partners but also as coordinators of welfare services. Consequently, it is essential for local governments to engage as stakeholders, define their roles clearly, and enhance their coordination capabilities [9,21]. In Korea, a pilot program integrating medical and social care support is being implemented to improve the coordination functions of local governments for discharged patients [29]. Evaluating the effectiveness of these initiatives is crucial. Additionally, to cultivate a collaborative environment, physicians, nurses, and social workers emphasize the importance of public awareness. They point out the need for initiatives aimed at altering patients’ perceptions.
In terms of reimbursement, the discharge support program faces challenges in providing appropriate compensation due to the varying amounts of time required for each patient. To address this issue, it is recommended to enhance outcome-based incentives, adjust reimbursement costs based on the average personnel time invested, and implement differential reimbursement that reflects the complexity of cases. A multidisciplinary team is a fundamental prerequisite for the success of a discharge support program. The formation of multidisciplinary teams for transitional care management has been shown to contribute to shorter patient length of stay and improved satisfaction. Additionally, it increases the satisfaction of service providers [30]. For the successful implementation of a discharge support program, it is crucial to ensure that compensation is adequate to sustain a multidisciplinary team.
Community integration involves collaboration among doctors. However, the persistent lack of coordination among medical institutions continues to be a significant problem. In Korea, communication between these entities usually happens only through documentation, which must be enhanced to guarantee the safe reintegration of patients into the community [24,28].
If the discharge plan is unclear, proper post-discharge management may not be achieved [24,31]. Currently, there are no accredited training programs for developing discharge plans. In addition to encouraging the formulation of discharge plans, it is essential to establish educational programs that include training on discharge planning during residency programs [32].
Our research extensively covered various occupations involved in different discharge support programs across Korea, and we encouraged broad participation by contacting all participating hospitals. Unlike previous studies that focused primarily on coordinators of public health and medical cooperation pilot programs [13], our study encompassed a broader array of programs and included a diverse group of service providers, not limited to coordinators. By emphasizing the perspectives of study participants through phenomenological analysis and incorporating solutions proposed by field personnel for identified issues, this research is expected to contribute to future improvements in these programs. However, the participation in interviews was limited to those who agreed to participate, which may have introduced selection bias. The phenomenological methodology relies heavily on the researcher’s interpretation and derives content through interactions with participants. Consequently, it is challenging to assert that the interview results are representative of all program participants [33,34]. Additionally, variations in the composition of personnel and resources involved in discharge support programs at each hospital could have influenced the responses; however, our study did not explore specific differences among hospitals.
In conclusion, the need for discharge support programs is well acknowledged, yet their effectiveness is hindered by several challenges. These include limited human and financial resources, inadequate awareness of the programs, the burdens associated with their implementation, and a lack of coordination functions. Addressing these issues could involve establishing suitable reimbursement and incentive structures that support the creation and sustained operation of multidisciplinary teams. Additionally, augmenting networks with community organizations and strengthening the coordinating role of local governments may help overcome these challenges.
Supplemental Materials
Supplemental material is available at https://doi.org/10.3961/jpmph.24.275.
Interview guidelines for doctors, nurses, and social workers
Characteristics of study participants by programs
Notes
Conflict of Interest
The authors have no conflicts of interest associated with the material presented in this paper.
Funding
None.
Author Contributions
Conceptualization: Choi JW, Yoo A, Lee H. Data curation: Choi JW, Yoo A, Bang H, Park HK, Lee H. Formal analysis: Choi JW, Lee H. Funding acquisition: None. Methodology: Choi JW, Yoo A, Bang H, Park HK, Lee HJ, Lee H. Project administration: Yoo A. Visualization: Choi JW, Lee H. Writing – original draft: Choi JW, Lee H. Writing – review & editing: Choi JW, Yoo A, Bang H, Park HK, Lee HJ, Lee H.
Acknowledgements
None.