Mapping evolving care needs in older adults with disabilities: a qualitative study

To construct a patient journey map visualizing the dynamic care needs of older adults with moderate-to-severe disability, and to develop a dynamic assessment tool for clinical nursing practice. The population of older adults with moderate-to-severe disabilities is growing, presenting complex physical and psychological challenges. Unmet care needs in this group are associated with increased adverse events and place a significant strain on healthcare resources. Current research lacks assessment tools that capture the dynamic nature of these needs across the care continuum, hindering the implementation of precise interventions. A qualitative descriptive study design was employed. Semi-structured interviews were conducted with 17 purposively selected participants (patients, family members, and healthcare staff). Interview transcripts were analyzed using Colaizzi’s phenomenological method. The patient journey was conceptualized into three phases: screening and diagnosis, inpatient treatment, and post-discharge rehabilitation and follow-up. The resulting journey map highlights the dynamic evolution of patients’ physiological and psychological needs across the three phases. A total of 28 themes were synthesized and categorized into three dimensions: tasks, emotions, and pain points. The care needs of older adults with moderate-to-severe disabilities are multidimensional and phase-specific. Addressing these evolving needs effectively requires a comprehensive support system integrating medical, familial, and social resources. The patient journey map serves as a valuable tool for dynamically identifying service gaps and facilitating personalized, timely interventions to improve patients’ quality of life and uphold their dignity.