Patient Perspectives on Care Transitions From Hospital to Home

Area of Science:

• Health Services Research
• Patient Experience
• Quality Improvement

Background:

• Understanding patient perspectives on care transitions is vital for identifying and addressing gaps in care.
• Improving the transition from hospital or skilled nursing facility (SNF) to home can enhance patient outcomes and system efficiency.

Purpose of the Study:

• To collect data on patients' experiences during care transitions.
• To identify factors influencing the completion of follow-up appointments after discharge.

Main Methods:

• A survey tool was developed with patient advisors and healthcare organizations.
• Telephone surveys were conducted with patients (or caregivers) 8-12 days post-discharge from October 2018 to December 2019.
• Data from 1257 patients were analyzed, focusing on care transition experiences and follow-up completion.

Main Results:

• Eleven percent of patients did not receive a post-discharge contact number; nearly 80% received a valuable follow-up call.
• Lack of transportation significantly reduced follow-up visit completion (OR, 0.31).
• Black patients were less likely to complete follow-up visits (OR, 0.49) and receive prescribed equipment (OR, 4.23) compared to other groups.

Conclusions:

• Patient discharge experiences highlight inconsistencies in care transitions and unmet social needs.
• Racial disparities exist in follow-up appointment attendance and equipment receipt.
• Physicians must recognize these factors to improve patient care transition experiences.