Discharging the complex patient - changing our focus to patients' networks of care providers.

Background A disconnect exists between the idealized model of every patient having a family physician (FP) who acts as the central hub for care, and the reality of health care where patients must navigate a network of different providers. This disconnect is particularly evident when hospitalized multimorbid patients transition back into the community. These discharges are identified as high-risk due to lapses in care continuity. The aim of this study was to identify and explore the networks of care providers in a sample of hospitalized, complex patients, and better understand the nature of their attachments to these providers as a means of discovering novel approaches for improving discharge planning. Methods This was a constructivist grounded theory study. Data included interviews from 30 patients admitted to an inpatient internal medicine service of a midsized academic hospital in Ontario, Canada. Analysis and data collection proceeded iteratively with sampling progressing from purposive to theoretical. Results We identified network of care configurations commonly found in patients with multiple medical comorbidities receiving care from multiple different providers admitted to an internal medicine service. FPs and specialists form the network's scaffold. The involvement of physicians in the network dictated not only how patients experienced transitions in care but the degree of reliance on social supports and personal capacities. The ideal for the multimorbid patient is an optimally involved FP that remains at the centre, even when patients require more subspecialized care. However, in cases where a rostered FP is non-existent or inadequate, increased involvement and advocacy from specialists is crucial. Conclusions Our results have implications for transition planning in hospitalized complex patients. Recognizing salient network features can help identify patients who would benefit from enhanced discharge support.