Technology Solutions to Support Care Continuity in Home Care: A Focus Group Study

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Elevated hospital readmission rates from home care are an indicator of poor care quality, and rates are particularly high for patients with heart failure. Readmissions may be avoided by optimizing continuity of care.


To explore perceptions among home care clinicians of the barriers they face and the information they need to improve care continuity for patients with heart failure.


Focus groups were conducted with teams of home care clinicians at a large certified home healthcare agency in the Northeastern United states.


In total, there were 61 participants across 6 focus groups. Three overarching themes emerged: continuity of care and communication on care transitions, maintaining continuity of care during a home care episode (with subthemes tracking signs and symptoms and patient teaching), and health information technology (HIT) characteristics to support communication and care continuity.


Our study highlights areas of improvement for HIT solutions that could support care delivery for patients with heart failure in a home care setting.


Home care agencies planning to introduce technology can use these findings to assess if and how potential systems can support nurses to provide continuity of care across healthcare organizations and home care visits.

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