Exploring expectations, needs, and preferences for home-based network care in frail older adults with heart failure: a qualitative study

Abstract Introduction Frail older adults with heart failure (HF) frequently experience fragmented care, particularly during the first weeks after the transition from hospital to home. This transition is associated with increased vulnerability, unmet care needs, and a high risk of unplanned readmissions. Home-based network care, involving collaboration between patients, informal carers, and healthcare professionals (HCPs) across primary and secondary care, may address the complex and multidimensional needs of these patients. However, limited insight into expectations and preferences regarding such network care exist. Purpose to explore expectations, needs, and preferences of frail older adults with HF, their informal carers, and HCPs concerning home-based network care during the transition from hospital to home. Methods A qualitative study was conducted using semi-structured interviews with older adults with HF (n=5), their informal carers (n=2), and HCPs (n=19) from hospital and primary care. Interviews addressed participants’ expectations during the transition from hospital to home, including challenges in current HF care, communication, and collaboration between those involved. Interviews were audio-recorded and analysed using thematic analysis. Results Participants expressed a strong need for timely, clear, and consistent communication between patients and HCPs, as well as across hospital and primary care. They emphasised the importance of effective interdisciplinary collaboration and clear task division to support continuity of care. HCPs suggested a dedicated nursing case manager, a single responsible professional who provides continuity by serving as a consistent point of contact and coordinator of care across settings. Older adults and their informal carers expressed a need for adequate information, knowledge, and support regarding medication, symptom management, lifestyle, and treatment adherence. They proposed to achieve this through educational sessions, tailored information materials, and structured counseling. Conclusion Home-based network care for frail older adults with HF requires clear central coordination to ensure continuity of care across care settings. Support need to include medication and symptom management, lifestyle, and treatment adherence. Consistent communication, adequate information and knowledge support for older adults with HF, informal carers, and HCPs were considered essential during the transition from hospital to home.