From Hospital to Home: Interdisciplinary Approaches to Optimise Palliative Care Discharge Processes

Matthias Unseld, Timon Wnendt, Christian Sebesta, Jana van Oers, Jonathan Parizek, Lea Kum, Eva Katharina Masel, Pavol Mikula, Hans Jürgen Heppner and Elisabeth Lucia Zeilinger ()
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Matthias Unseld: Department of Clinical Research SBG, Academy for Ageing Research, Haus der Barmherzigkeit, 1160 Vienna, Austria
Timon Wnendt: Department of Clinical and Health Psychology, Faculty of Psychology, University of Vienna, 1010 Vienna, Austria
Christian Sebesta: Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria
Jana van Oers: Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria
Jonathan Parizek: Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria
Lea Kum: Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria
Eva Katharina Masel: Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria
Pavol Mikula: Medical Campus Upper Franconia (MCO), Friedrich-Alexander University Erlangen-Nuremberg, 91058 Erlangen, Germany
Hans Jürgen Heppner: Medical Campus Upper Franconia (MCO), Friedrich-Alexander University Erlangen-Nuremberg, 91058 Erlangen, Germany
Elisabeth Lucia Zeilinger: Department of Clinical Research SBG, Academy for Ageing Research, Haus der Barmherzigkeit, 1160 Vienna, Austria

IJERPH, 2025, vol. 22, issue 7, 1-12

Abstract: The transition from hospital-based palliative care to home care is a critical phase often marked by logistical, medical, and emotional challenges. Effective discharge planning is essential to ensure continuity of care, yet gaps in communication, interdisciplinary coordination, and access to resources frequently hinder this process. This qualitative study explored key barriers, related support needs, and strategies for optimising palliative care discharge through semi-structured interviews with 28 participants, including healthcare professionals, recently discharged palliative care patients, and primary caregivers. Reflexive thematic analysis revealed five main themes: (1) discharge planning and coordination; (2) symptom management and medication; (3) psychosocial support; (4) communication and information; (5) the role of assistive devices and home care services. Discharge processes were often late or unstructured. Poor interdisciplinary collaboration and a lack of caregiver preparation also contributed to hospital readmissions and emotional distress. By focusing on needs, our analysis identifies not only what was lacking but also what is required to overcome these barriers. Our findings suggest that standardised discharge protocols and checklists, earlier planning, structured communication tools, and improved integration of home care services could enhance patient outcomes and reduce caregiver burden. Addressing psychosocial needs and ensuring timely access to assistive devices are also crucial. Strengthening interdisciplinary collaboration and refining discharge practices can facilitate smoother transitions and improve the quality of palliative care at home.

Keywords: discharge planning; end-of-life care; home-based care; hospital discharge; interview study; palliative care; qualitative research (search for similar items in EconPapers)
JEL-codes: I I1 I3 Q Q5 (search for similar items in EconPapers)
Date: 2025
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Persistent link: https://EconPapers.repec.org/RePEc:gam:jijerp:v:22:y:2025:i:7:p:1023-:d:1689244

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