[Differences Between Visiting Nurses and Patients/Families in the Perception of the Difficulties in Intervening Immediately After Hospital Discharge].

The implementation of medical home care requires the fulfillment of discharge coordination and planning, but some hospital nurses face difficulties due to differences in perception between nurses and patients/families. Visiting nurses involved immediately after hospital discharge also have difficulties in providing at-home care and struggle with differences in perception. This study clarifies the differences between visiting nurses and patients/families in their perception of discharge immediately after hospital discharge and suggests a way to resolve those differences. We also examine an ideal approach to discharge coordination and planning. We conducted a survey of 100 visiting nurses, and the results from 81 responses (validity rate: 81.0%) showed that the differences in perception were "different for all: visiting nurses, patients, and family members," with "need for care content" and "perception of prognosis" being the most frequent responses. Methods of resolving differences were categorized as "respect for intentions," "explanation," "intervention during hospitalization," "coordination with patients/families," and "service coordination". To resolve the differences in perception among nurses, it is important to start interventions by visiting nurses during hospitalization through collaboration between hospital and visiting nurses. Seamless support until after discharge, respecting the wishes of patients/families, careful explanation of the patient's condition, including prognosis, and the step-by-step planning of discharge coordination by the team are also important.