Care Transitions From Patient and Caregiver Perspectives.

Area of Science:

• Healthcare delivery research
• Patient and caregiver experience
• Health services research

Background:

• Hospital to home transitions are critical but often hazardous.
• Limited understanding exists regarding patient and caregiver experiences and valued outcomes during care transitions.

Purpose of the Study:

• To describe patient and caregiver experiences during care transitions.
• To identify desired outcomes and associated health services for effective care transitions.

Main Methods:

• Qualitative study involving 138 patients and 110 family caregivers across 6 US health networks.
• Utilized focus groups and key informant interviews, with data analyzed using grounded theory principles.

Main Results:

• Patients and caregivers desire to feel cared for, experience unambiguous accountability, and be prepared for self-care.
• Key services/behaviors include empathic communication, anticipating needs, collaborative discharge planning, actionable information, and care continuity.

Conclusions:

• Achieving patient-centered outcomes like accountability, continuity, and caring attitudes transforms transitions from transactional to trustworthy.
• Failure to meet these outcomes results in perceived abandonment and unsafe care experiences.