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Homeward bound: patients’ perspectives on care transitions after a hospitalization

Nathaniel Avery Erskine, Milena D Anatchkova, Benjamin E Shirley, Hawa Abu, David D McManus, Catarina I Keefe, Heena S Santry


Background: Suboptimal care transitions from the hospital to home (transitions) may lead to adverse patient outcomes. As reimbursement becomes increasingly linked with clinical and patient-centered outcomes, providers have strong incentives to better manage transitions. Patients may offer key insights to better assess and improve transitions.

Methods: In this qualitative study, we performed semi-structured concept elicitation interviews with patients experiencing a transition following an unplanned hospitalization in medical and surgical wards at a single academic medical center. Three analysts independently analyzed transcripts to identify themes within and outside the medical centers that influenced patients’ transition.

Results: Our analyses of interview transcripts of patients (n=22) identified 4 themes related to actions of discharging medical centers and 5 themes outside of the direct purview of the discharging hospital that influence transitions. In the medical center, participants generally described positive roles for quality patient-centered care, opportunities for patient participation, comprehensive discharge education and coordination of medical services on their transitions. Outside of the medical center, participants reported that having caregiver support, social support, health literacy, adequate health insurance and accessibility to healthcare and non-healthcare resources following hospital discharge assisted their transitions.

Conclusions: This qualitative study suggests that successful transitions result from actions of medical centers to engage and assist patients, as well as from patients’ access to sociodemographic and psychosocial resources. Future work on strategies to develop better patient-centered transitions and their impact on patient outcomes is warranted.


Caregiver support, health literacy, hospitalization, individualized care, patient-centered outcomes, patient discharge, patient education, patient perspectives, person-centered healthcare, qualitative research, quality of healthcare, transitional care

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