{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T21:32:53Z","timestamp":1790803973587,"version":"4.1.0"},"reference-count":27,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2025,6,27]],"date-time":"2025-06-27T00:00:00Z","timestamp":1750982400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"University of Vienna"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>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.<\/jats:p>","DOI":"10.3390\/ijerph22071023","type":"journal-article","created":{"date-parts":[[2025,6,30]],"date-time":"2025-06-30T03:54:28Z","timestamp":1751255668000},"page":"1023","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["From Hospital to Home: Interdisciplinary Approaches to Optimise Palliative Care Discharge Processes"],"prefix":"10.3390","volume":"22","author":[{"given":"Matthias","family":"Unseld","sequence":"first","affiliation":[{"name":"Department of Clinical Research SBG, Academy for Ageing Research, Haus der Barmherzigkeit, 1160 Vienna, Austria"},{"name":"Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Timon","family":"Wnendt","sequence":"additional","affiliation":[{"name":"Department of Clinical and Health Psychology, Faculty of Psychology, University of Vienna, 1010 Vienna, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-7504-8506","authenticated-orcid":false,"given":"Christian","family":"Sebesta","sequence":"additional","affiliation":[{"name":"Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jana","family":"van Oers","sequence":"additional","affiliation":[{"name":"Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan","family":"Parizek","sequence":"additional","affiliation":[{"name":"Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7751-7994","authenticated-orcid":false,"given":"Lea","family":"Kum","sequence":"additional","affiliation":[{"name":"Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6415-4488","authenticated-orcid":false,"given":"Eva Katharina","family":"Masel","sequence":"additional","affiliation":[{"name":"Division of Palliative Medicine, Department of Medicine I, Medical University of Vienna, 1090 Vienna, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-5974-9844","authenticated-orcid":false,"given":"Pavol","family":"Mikula","sequence":"additional","affiliation":[{"name":"Medical Campus Upper Franconia (MCO), Friedrich-Alexander University Erlangen-Nuremberg, 91058 Erlangen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9105-720X","authenticated-orcid":false,"given":"Hans J\u00fcrgen","family":"Heppner","sequence":"additional","affiliation":[{"name":"Medical Campus Upper Franconia (MCO), Friedrich-Alexander University Erlangen-Nuremberg, 91058 Erlangen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0625-500X","authenticated-orcid":false,"given":"Elisabeth Lucia","family":"Zeilinger","sequence":"additional","affiliation":[{"name":"Department of Clinical Research SBG, Academy for Ageing Research, Haus der Barmherzigkeit, 1160 Vienna, Austria"},{"name":"Department of Clinical and Health Psychology, Faculty of Psychology, University of Vienna, 1010 Vienna, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,6,27]]},"reference":[{"key":"ref_1","unstructured":"(2025, June 22). 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